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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER NAME <br /> Scott ,� <br /> l.�or i l'."1 01 ►! Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 4 Deed Restriction; CSM <br /> qa 80 Cr 41 i, <br /> .c (c. C t L,- E STS ?3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 602 q6 T-Soo,-( 1 Sc-, S'B s -,,,u;/. ‹,,,,,, EiSite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 9 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 12f Setbacks <br /> PHONE PHONE ❑Site Pla proval from <br /> appf le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS liFI or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PAR L NUMBER: 'QC7 q CURRENT ZONING: ACREAGE: P P rty <br /> ❑ <br /> N PARCEL UMBER <br /> O O / -/ ( ( ,,od 0 ,,,i/ i_ a-- frontage drawn to scale. <br /> TOWNS IP: / SECT(Op4� _ /� <br /> c k >u r / L�IJ '/.: ■S %IA: �/-_ ❑Drive permits <br /> ADDRESS: /l.lz O � Ow (st e,county,town) <br /> CSM: (�/ LOT SUBDNISION BLOCK/LOT ❑Sani permits <br /> private) <br /> ( O t II .. (P ic,P ) <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> e c.� S r, ,./- 1 ing District <br /> . ❑This project is a new building or structure. ermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ki ❑ Rural •d - <br /> EWER MEPTIC (new/3,1 sting <br /> HEIGHT IN FEET: 4,1 / NUMBER OF STORIES: (Not in uding ment) <br /> ❑ Wetla •+ ••plain/ <br /> AREA TO NEAREST SQUARE FOOT: and (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �0 ❑ (slop rtur permit <br /> TOTAL SQUARE FOOTAGE: 4, (sl ,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 7>0 tI • access) <br /> ❑ Review Location Survey f)0.) <br /> ESTIMATED CONSTRUCTION COST: -i and available options. <br /> -4.(Please round to nearest dollar) $ _RlL5 vU• v0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑1'es rao ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ges o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑1'es ( Jo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leav lank i none) <br /> 6. Is a location survey required? (see reverse) s o ❑Don't know <br /> 7. Is this to correct a violation? es 10 <br /> 8 0 APPLICATION MUST BE SIGNED <br /> O (Continue on Back) -4 -4 -► <br /> 545-112(4108) 44 I 1 • <br />