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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVI E <br /> OWN ER E <br /> C # _ 2 <br /> eLAid 5c`i.---{'{ Zoning Status; CUP; <br /> OWNE ADDRESS (Dumber,Street,City,State,Zip) Deed Restriction; CSM Z f 2. <br /> 7 5'2_9 Fe ((n co nsl Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Z- /65- Ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions A,� <br /> AGENT NAME CONTRACTOR NAME <br /> //054 5�r--,p`l / 4)e c_4 Site Plan including location "1 <br /> AGENT AVDRESS CONTRACTOR ADDRESS of w II/septic <br /> G 30 S rcs P de' A/2S//� <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> : <br /> PHONE /A e �� � PHONE ❑ Site Plan approval from <br /> Q$ S Z - (Z5—;- applicable township. <br /> E-MAILADDR E-MAIL ADDRESS <br /> KI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ,I21_Elevation of property <br /> ❑ PARCEL �p q Ap q �L , LP frontage drawn to scale. <br /> NUMBER C(/1—0!�'(,1! /t7' L � z- 1 <br /> TOWNSHIP: SECTION: ■ <br /> in- X1/6 1/4: 5 1/41/4: 5,,,,.._ a_Driveway <br /> > pe <br /> (state, county, <br /> own <br /> ADDRESS: <br /> 7 e" ZR J-" / (srw rt7( L - j � $5� <br /> A:Sanitary Cs_ <br /> CSM: LooTT SUBDIVISION BLOCK/LOT (public, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> z3 r k f'8 - d 9f)eGi p L 3 )( �0 l' .2- Zoning District .Z <br /> . ❑This project is a new building or structure. e'v" C c- `�"" <br /> Q � Permitted Use? �,/ <br /> [This project is an addition/alteration to an existing building or structure. �9 , C`K <br /> SANITARY SERVICE: PERMIT NUMBER: , Rural Address <br /> [1SEWER [SEPTIC - (ne t. <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) <br /> Z--( ,,- a(Wetland/Floodplain/ / <br /> AREA TO NEAREST SQUARE FOOT: / Ofe (attachment) �4) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: / / / / .ErospionControl permit / <br /> �/ / 7 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, / <br /> 2ND FLOOR: 3RD FLOOR: ((( filling/access)/ <br /> /Review Location Survey //��//��J <br /> ESTIMATED CONSTRUCTION COST: $ G J ©© O V and available options. ' /j_ <br /> (Please round to nearest dollar) ♦ ..+ ♦ O // <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes g No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? n Yes tri No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes M No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No 7 <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) nYes irj o ❑Don't know <br /> 7. Is this to correct a violation? EYes Ai No <br /> APPLICATION MUST BE SIGNED <br /> gi (Continue on Back) -i <br /> 545-112(4/08) <br />