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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OER NAME <br /> L Zo 'ng Status; CUP; <br /> OWNER A R S4Number, et,City,State,Zip) D d Restriction; CSM <br /> ��ds � �' ,. l�L)l 53503 riance(# ) <br /> HOME PHONE CEL PHONE E-MAIL ADDRESS <br /> .W1-48 too'OALt of I o• S\ @ bS, I've. S' a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> b S' Plan including location <br /> AGENT ADDRESS C NTRACTOR ADDRESS well/septic <br /> CONTRACTOR <br /> 3156 <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> merge,, LOO S3 <br /> PHONE PHONE ❑Si Plan royal from <br /> 1k ' W-(-f(I 4 plica township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor pl to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) r0 f o <br /> Elevation <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> ❑UMBER 0 5 O"Z a- 211 7 000 � 4.04 <br /> frontage drawn to scale. <br /> TOWNSHIP: I SE • - <br /> p-l1 _�k ,/4:S '/4'/4: ± ❑Drivew ermits <br /> ADDRESS: - (sta ,county,town) <br /> 8 L 66 Rd ,� ��Je ko ita-e., ,W I -61S62 <br /> CSM: LOT SUBDIVISION BLOCK/LOT I:]Sanita ermltS <br /> (p W. ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S.ac , .,3 q 7< 3 cDI ► oning District <br /> . <br /> This project is a new buildin or structure. <br /> Permitted Use? <br /> ❑This project is an addition/ Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ( ❑ Rural A.. _• <br /> FIEWER EPTIC (new/e isti .) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not ncluding basement) <br /> Wetland/ plain/ <br /> a ), y�"'' ) CI Shor nd (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: ❑ OSIOn�iOn permit <br /> 191li + TOTAL SQUARE FOOTAGE: ,j slopes, ' rbance, <br /> filling/ ss) <br /> 2ND FLOOR: 3RD FLOOR: 1 <br /> I ett44 Review Location Survey <br /> l '(1) <br /> ESTIMATED ED CONSTRUCTION)COST: ♦ ♦ •. - ♦ ♦ $ . and available options. <br /> (Please round to nearest dollar) (jet 06 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ao <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 ow ['Don't know <br /> 7. Is this to correct a violation? ❑Yes JIo <br /> S ' RO APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> 1 (Continue on Back) ■ ■ -∎ <br />