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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME t� <br /> Ashley umrick ❑Zoning Status; CUP; <br /> OWNER ADDRESS ber,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 3�y0 old S e S�`ov5t1}Uh, wl c c Variance(# ) <br /> HOME PHONE I CELr PHONE E-MAIL.ADDRESS�1 <br /> 1 6ce- ss$-469.o tot Ex nwqr3 e tA-ww-cclt t_ n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> clPorf CoYarlk hbA ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> a.10 L tlt`COI►n S <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> 15“ CITI , w1 s3Sa1 <br /> PHONE PHONE ❑Site Plan approval from <br /> 600-ton lA318 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Old or+cons h lAc4- G mad- co M ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusn ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL osa/os10-3cI-18co-1 A-1 (EX) S•Ub"1 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> TOWn. Ok I ka nd v.: 1,4%. n Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3 990 old S qe Yid _ ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: q <br /> Pe0( 14 ) I ❑ Zoning District <br /> ❑This 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: ❑ Rural Address <br /> EWER EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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 /> ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: ti V <br /> 1 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> q 0 1p Cl Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ Q� and available options. <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? f Yes FIN() ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No eDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? res `,❑�No <br /> ❑ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave bl nk if none) <br /> 6. Is a location survey required? (see reverse) T]Yes 'lo ❑Don't know <br /> 7. Is this to correct a violation? nYes R]No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —+ —+ <br /> 545-112(4/08) <br />