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. ZONING PERMIT APPLICATION www.countyofdane.com <br /> !II:21213:=7 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /' <br /> KEG G C�DE/E 1( ❑Zoning Status; CUP: <br /> OWNER ADDRESS <br /> (Number.Street,City,State,Zip) <br /> /�,� Deed Restriction; CSM <br /> 51-iM SSO3 gI -4� I'�B SWRL ,-)ALT c.,aS'S_°L Variance(# ) <br /> HOME PHONE CELL PHONE I E-MAIL ADDRESS <br /> - •4 S- 8913 Ggs6, E lE/t A Nod , 0.4 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME I CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS I CONTRACTOR ADDRESS of well/septic <br /> ;City.State.AiG I(City.State,Zip) ❑Setbacks <br /> PHONE I PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MiAII..ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT I PARCEL NUMBER: CURRENT ZONING:_ ACREAGE: <br /> ❑Ruti% , 0812-e(o 2.92 Zo -b A -_I_ Z. o_ frontage drawn to scale. <br /> TOWNSHIP. SECTION: / / ❑ Driveway permits <br /> 1 1 6 1D ri A 1 4: ,A ytt. <br /> ADDRESS (state, county,town) <br /> 5-1_7...4.__m )sse m?� 12� Mv)eS N4LL 1J , c3S <br /> CSM: LOT I SUBDIVISION 3 I BLOCK/LOT ❑Sanitary permits <br /> I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> � '�'z-bt7lo,, 13')(3o' ro�T jstc. H Six 8 ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> EtThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE 1 PERMIT NUMBER: j Rural Address <br /> EWER EPTIC (new/existing) <br /> HEIGHT IN FEET I NUMBER OF STORIES: (Not including basement) <br /> %, p^ U Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 7"1 ErosionControl permit <br /> 1 TOTAL SQUARE FOOTAGE: ,l (Slopes,disturbance, <br /> 3C.4 - filling/access) <br /> 2ND FLOOR 3RD FL..00R: 3O <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: QQ� 8" <br /> and available options. <br /> (Please round to nearest dollar) $ � Ott) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eves No EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ON ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes No <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) Eyes No ❑Don't know <br /> 7. Is this to correct a violation? EYes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4.08) <br />