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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 /> /T./l 7-46//tie' -74 psi, v r /12/4220/, 0 Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM
<br /> / 7/V ��TLK23e/t�b e/t Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> 47/4/ - ' ['Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> hid/,SE,v 6r(////IA'S- 1',t,/C ._ / I S f ti /-3,;,?',/.:/.,°'4"s �.� ['Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> //O 6/44 . s{ s✓/7?S //, X" - 5", s ` ' g"
<br /> (City,State,Zip) (City,State,Zip) ['Setbacks
<br /> L/,.►v t/ 'c`L,! 'c. ,. . 57` ' G(.41,A/A k -6 Gc/Z . 5'3r 52
<br /> PHONE PHONE ❑Site Plan approval from
<br /> 4c -f e1<>-- v '7y- '9 j (-/1/•— V736 applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> /414, ,:',' ;,", ':.4.7.,e f n-' ?'.r'i,A t 74 `l e-n/SC,v 6u//11 R c & Tas,/v1.-14- ❑Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:
<br /> N EL a?f/O7a 1-19V-6///-/ /4-/ /' V93 frontage drawn to scale.
<br /> NUM UM BER
<br /> TOWNSHIP: SECTION:
<br /> /YI k1/41.9■1/4J /c/ .1/4: 5 1/4'/4: S E ❑ Driveway permits
<br /> (state,county,town)
<br /> ADDRESS:
<br /> 71.-3s fJt /CL, ,,t 0A1✓i El Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> / 3 S,'.'( Ft,„T rc.'`,
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> 140 ,, ❑ 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 /> [)EWER EPTIC /3-,70/f- ad/1/ (new/existing)
<br /> HEIGHT IN 3 T�/ NUMBER OF STOIES: (Not including basement) ❑ Wetland/Floodplain/
<br /> 3 .2- 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: r-, ErosionControl permit
<br /> �y 7/ t 7 . 07 ,, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance,
<br /> 7 filling/access)
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> 5-9 9/734).0 ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: $ / r/O and available options.
<br /> (Please round to nearest dollar) ♦ ♦ '♦ ♦ ♦ / 6 �JO
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes IgNo ['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? ['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 ONo
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -+ -* -o.
<br /> 545-112(4/08)
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