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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O ER NAME <br /> CU7TOMER <br /> \--AM e/LS ❑2o ng Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D ed Restriction; CSM <br /> ci S‘o y urn • Q∎Z STQU.)0o.v We S 3 5CM V riance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> A- 3 tiaQ 5 •e:-333 y b`�c' NA'Lokm = A J*. -1-- e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION n ncludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S.a Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks ���� <br /> PHONE PHONE ❑Site Plan appr Y fral ;n- <br /> a plicabl wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ❑ <br /> lour s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: �j CyRRENT ING: ACREAGE: Elevation of property <br /> ❑ <br /> NUMBER v I r^/i , cj/ ��-r %,1 }' frontage drawn to cafe. <br /> TOWNSHIP: SECT•• �'" <br /> 1 `,? r\k, (� 7 '/4: /�/ I\'/4'/4: ❑Drivew ermits <br /> ADDRESS: (sta ,county,town) <br /> 1) C~" % ❑ -nita •ermits <br /> CSM: LOT SU IVI BLOCK/ <br /> Apr • i% • ' ,private) <br /> S�.Ad e A id t4 0 w , <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIO <br /> '( /q ,ter'• - --\ e�� V' ' a Or\ 1/Zoning District <br /> ❑This project is a new building or structure. r Permitted <br /> This project is an addition/a ration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: / LI RuralA dress <br /> EWER PTIC / (new/e fisting) <br /> HEIGHT IN FEET / \ ' NUMBER OF STORIES: (Not including basement) <br /> I d j ❑ Wetland/FI• A plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorela•• (attaC nt) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ Er. IonC rol permit <br /> &5C, 4, TOTAL SQUARE FOOTAGE: 4, (slope isturbance, <br /> 2ND FLOOR: 3RD FLOOR: (2.?— fillip access) <br /> S; <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 5 OOH and available options. <br /> I'UO <br /> (Please round to nearest dollar) p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [5 10 ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EgNo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Eyes ❑INo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes gtlo <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 Jlo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes [.No <br /> cpAPPLICATION MUST BE SIGNED <br /> 9 (Continue on Back)(4/08) ( ack) ♦ —► <br /> .4( g , <br />