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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 /> J k v y /�(� / <br /> 0 <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Str et,City tate,Zip) Deed Restriction; CSM <br /> M 1() 2. S a h c% c e r Ttc i/ C o 7 af{ �v 0 v.. Y Varia nce(# <br /> ) <br /> HOME PHONE CELL PONE E-MAIL ADDRESS(' <br /> G 0 43 9-y'',2 y 0��JS-df//fe Q-A 00 I /D ; , , , Ir, ❑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 /> / <br /> PARENT PARCEL NUMBER: CURREN ONING: ACREAGE: <br /> ®PARCEL O �z ` , /'I t ^ '1 ,6 frontage drawn to scale. <br /> f O <br /> NUMBER 0 *7//- Sy oZ (o <br /> TOWNSHIP: SECTION: <br /> C a .l v� G,a F p S 'A: .1/4%: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 11.0 Z ,C?PI 4/r 71rA �o' o (y ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> • o o .' <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:K00/41 � ^D 77/ O <br /> �l/LAO f�J�J CI Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER VEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /- ©/Vt LI 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 /> BASEME T: 1ST FLOOR: is <br /> q ❑ ErosionControl permit <br /> i/ % , TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD 00R. filling/access) <br /> /57 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: d� and available options. <br /> (Please round to nearest dollar) -0. ♦ .-10. ♦ ♦ ♦ $ c2 Q CM <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 12No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes jNo ❑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? ❑Yes 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) ❑Yes ❑No ®Don't know <br /> 7. Is this to correct a violation? ❑Yes QNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ■ -► <br /> 545-112(4/08) <br />