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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> (� M.G o Ay } E 1 <br /> OWNER AD ESS (Number,Street,City,State,Zip) <br /> t-1 ❑Zoning Status; CUP; <br /> �LI C/1,,r)/(, f 064:02-10 r/ w/ t 75 7 V Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> c 3 8 8`17 r'05 g-1-11 C9i s n . a M ❑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.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑NUMBER 5-/2 -fill "et 3 57- - , S frontage drawn to scale. <br /> TOWNSHIP: SECTI N: <br /> n g F M L a /o '/4: S 121 WA: 5 W ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3`{t1 Cam/ 6 R..0 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> CSM cf;q <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6/9 R/616 E ❑ Zoning District <br /> . laThis project is a new building or structure. ❑ Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER FIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> t) c2 + TOTAL SQUARE FOOTAGE: $, (slopes,disturbance, <br /> U filling/access) <br /> 2ND FLOOR: 3RD FLOOR: / O Q <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) $ t ? 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes D"io Jon'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? ❑Yeslo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [ Yes EiNo <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 o ['Don't know <br /> 7. Is this to correct a violation? Oyes alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ <br /> 545-112(4/08) <br />