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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 /> -7: V 7,'�'e/r^ i9Ll� " /_''9L/ 1/4/,/ C'¢'°1/° ❑Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> 2D33 ,if.S/ '-/, yV1 1a'1 4 / ?,� Deed Restriction; CSM
<br /> HOME PHONE CELL PHONE / Variance(# )
<br /> E-MAIL ADDRESS
<br /> 27:tr ❑Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> /lei 0,~,r�� 't-� ❑Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) // (City,State,Zip) ❑Setbacks
<br /> PHONE PHONE ' n Site Plan approval from
<br /> 44,1*— :A'j_ iir(/ applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> AO ST� , 0 d v..E,,,eedca41- El Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/)
<br /> PARENT PARCE NUMBER:/ f CURRENT ZONING: ACREAGE: ❑Elevation of property
<br /> ❑PARCEL 7-N2-27/o..o C2 //�7 frontage IJ70 ,, fronts a drawn to scale.
<br /> TOWNSHIP: SECTION:
<br /> 7a4,,e/ Of ,6,/,,v/3.,A/ /VA) 1/: ,l€) 14Y4;1,, e.; ❑Driveway permits
<br /> ADDRESS: (state, county,town)
<br /> 2e,33 f%1,,0-A, 1 t /D j 41440/0,,si, if--/ f 971 S
<br /> CSM: SUBDIVISION BLOCK/LOT El Sanitary permits
<br /> /1"0 / (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> A/Kiel / e,EE`>'4^49�4ff �,p/✓m y ✓�7,IfGT e. ❑ Zoning District
<br /> ❑This project is a new building or structure.
<br /> CI Permitted Use?
<br /> OThis project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address
<br /> EWER SEPTIC (new/existing)
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> /,? / ❑ Wetland/Floodplain/
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> Shoreland (attachment)
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> BASEMENT: 1ST FLOOR: I—, ErosionControl permit
<br /> 21 7 > .x 2 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance,
<br /> 2ND FLOOR: 3RD FLOOR: / filling/access)
<br /> i
<br /> • •
<br /> ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ ♦ ♦ ♦ $ 2 and available options.
<br /> (Please round to nearest dollar) 3,�5vO
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑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? Elves 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) Elves ®No ❑Don't know
<br /> 7. Is this to correct a violation? Elves ao
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue Back) -► -i -►
<br /> 545-112(4/05) ( ue on ac )
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