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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA <br /> ,.. -71114/ t •L u,re <br /> O <br /> EJ <br /> WNER ADDRESS (Numb r,Street,City,State,Zip) <br /> Zoning Status;CUP; <br /> /1O5 IESI/i/� lo,.P Deed Restriction; CSM <br /> �ZFIGI.ID W� 53531 Variance(# ) <br /> HOME PHONE/ CELL PHONE E-MAILIADDR S <br /> 9°240 <br /> -76- 0 5mE - `uec skk-/o4t .4d74 E]Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1 <br /> AGENT ADDRESS K '. %R pVI l) DQA 1�.5 CO ❑Site Plan including location <br /> C'ONNTTR,A�Cr TOORAADDRESS_ b of well/septic <br /> (City,State,Zip) Po-rac ~ . <br /> (City,State,Zip) ��r�+ 1�,y t ❑Setbacks <br /> PHONE �� IWI w�- fic7/� <br /> PHONE ❑Site Plan approval from <br /> Gob'Q)b6.615q applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> I _ fj c . , 74 , t,.coil,‘ ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (htt//accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> 0 PARCEL 0'1 1 la•O91 O frontage drawn to scale. . <br /> �►3 5 P... , g <br /> TOWNSHIP: SECTION: <br /> •DC�:RV Ie,1 1A: ,/4,/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 1105 NE-5 ► W P.O. br,b.erie.4.4 Krz 53531 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5CR RO .$N P3I2Cki ❑ Zoning District <br /> ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: t NUMBER OF STORIES: (Not including basement) <br /> 1 L4 i ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl(?errrlit <br /> ,, ,l TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> Ifs*1a ta= I�Q filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey,,;' <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ '+ '♦ ♦ —► $ 13!S(X) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes No ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes ENo EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? OYes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes f 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) Efres No ODon't know <br /> 7. Is this to correct a violation? QYeslo <br /> 4 cl APPLICATION MUST BE SIGNED <br /> 54e-112(4/08) (Continue on Back) —■ <br />