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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME DR A) L. )< ?13 FT ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed <br /> Restriction; CSM <br /> X 93G, NN DRoL ` R. Variance(# /6 3 z <br /> ) <br /> HOME P E-MAIL ADDRESS <br /> 4;82-3D 4 L $4veve ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZO G:! ACREAGE: <br /> ❑PARCEL <br /> UM EL 0.)i/ •0(..ii�/q - –I frontage drawn to scale. <br /> NUMBER ((OOH/� <br /> TOWNSHIP: SECTION: <br /> (At C G�v e & 1/4: ,/4,/4: D Driveway permits <br /> ADDRESS: (state,county,town) <br /> ag3c Ncnc' " C <br /> ❑Sanitary permits <br /> CSM: LOT IS BLOCK/LOT <br /> �dpp11, (public, private) <br /> (vas, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> % 1S+ \ 14$1L ' <br /> a.1 ''De c.1,4 rear c!f ill.oat ❑ Zoning District <br /> . ❑.nis project is a new building or structure. ❑ Permitted Use? <br /> RThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPTIC — (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 7 Z-l <br /> `� / ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --/o. —o. ♦ �,`oo and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [7�No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? RYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies 12No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes Elo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes 2No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —0. -+ <br /> 545-112(4/08) <br />