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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA /^ <br /> an v /5efil ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,//City,St ate Zip) f / 9 Deed Restriction; CSM <br /> a0�r Street, <br /> /°( of C0//�1 �r0(/�J W / r Variance(# ) <br /> HOME PHONE /CELL PHONE E�IAILADDLRES4 <br /> .- -/,,'1 hi re T ,l, 1 A C < (0%1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CON RACTOR NAME <br /> d/Y'/fD4 G6/16-/ O-h �/1G, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A RESS of well/septic <br /> /5-00 A/7aii'l,,i 61!� <br /> (City,State,Zip) (City,State,Zip) J El Setbacks <br /> /'lr Vaah� Iee� G&/i <br /> 3, f 7 <br /> PHONE PHONE El Site Plan approval from <br /> 60g _ 35--. <br /> 5— _450 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ' a i 0 /-1 , e ❑ Floor plans to scale <br /> PROPERTY/LOCA <br /> -7TION INFORMATION (http://accessdane.co.daAnc .us/) ❑Elevation of property <br /> ❑NUMBER Mil ELI 8%0 K CUfj),2 ZONING:-S�� ACOlt 1 sS g <br /> PARCEL 'FV ,`t( fronts a drawn to scale. <br /> TOWNSHIP: SECTION: <br /> CO o /, 0 -(nv.,� '/4: 1/41/x: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> dot S t <br /> e �c ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: • <br /> S .60 LA � �: • `F �QR 1' L Zoning District <br /> . ❑This project is a new but ding or structure. 0 Permitted Use? <br /> UThis project is an addition/alteration to an existing building or structure. [ <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> EWER EPTIC (new/existin ) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2 0 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. 1 ST FLOOR: 0 ErosionControl permit <br /> D 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: �� 3RD FLOOR: —I I l filling/access) <br /> J a i L# Review Location Survey 0 <br /> ESTIMATED CONSTRUCTION COST: _o, ♦ ♦ ♦ $ and available options. <br /> (Please round to nearest dollar) $ ��J d�� <br /> -# 383-° <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? •► -s JNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 0 es laio ►2 Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0 es ❑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) Ekes a o EDon't know <br /> 7. Is this to correct a violation? ❑Yes In o <br /> 4 53 . 100 APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -+ <br /> 545-112(4/08) <br />