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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME N CA. c� 'c) <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 1 p�� f,�c� 1, C T Z f� Deed Restriction; CSM <br /> —1�2. t er\A ov eke Za•C sJ P A AS, bil5S52 Variance(# ) <br /> HOME PHONE CEL PHONE/ E-MAIL ADDRESS �j � L <br /> (r ,'SI(P"1l8Z �l-te US ��'"T ❑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/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: R CURRENT ZO++NING: ACREAGE: <br /> ❑NUMBER RC oBc 8_( L .% 0 -f R 1 7,3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> S ��Q�d -1.. ,/: IAA ,%, : 5e ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> -11 W c cA\c* \\\Z16' CCO SSA)\CiL' MILOI C S ❑Sanitary permits <br /> CSM: LOT j� <br /> SUBDIVISION BLOCK/LOT <br /> / A <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Iskuo age Cod�?�cvCA.\00 ❑ Zoning District <br /> EIThis project is a new building or structure. LI Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: y CI Rural Address <br /> EWER �EPTIC 13-- 20 'S - 001�) (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> cam, <br /> 2 O. S 2 ❑ Wetland/Floodplain/ <br /> Shoreland (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: ( <br /> ❑ ErosionControl permit <br /> VIM �1 100 2. ,ar, - + TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> �V filling/access) <br /> 2ND FLOOR: 1 J 3RD FLOOR: t ' 5� <br /> I..t1 ' 1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION)COST ♦ ♦ !, nom\O and available options. <br /> Please round to nearest dollar) v a 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes EINo ❑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 Io <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves ®No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# +(2-4-33 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) gkes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Lives ,®No <br /> C.--v <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) / 2� ` (Continue on Back) -. -4, - <br /> II. <br />