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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 /> � ' /AM0 Ry Ithir /. -ir Z,m c#,v evei-e&Y E Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> /8 Qa / 6-/ /� i1rai/ Id� Deed Restriction; CSM <br /> G(S y >' 6 Variance(# ) <br /> HOME PHONE C LL PHONE do 7 E-MAIL ADDRESS <br /> r '-;2 4 1/ _ _ - ;73 3Gy7T4fc <br /> / <br /> �C. 1-2 ❑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.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑UMBER ©6/0 a S 3 - q a� R1/-3 /D.a frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 7(0ti� 49 /A 5-a)1/4: 1/414: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJEC DESCRIPTION: ,1 Q <br /> iz�o•Znv /-,�C. gjyt,r S,6 w "V , /v g Z 'G,fej 0 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: 0 Rural Address <br /> [)EWER rEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> a Far 0 Wetland/F000dplain/ <br /> 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: <br /> 0 ErosionControl permit` <br /> ,` TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 'ra S4 <br /> © Review Location Survey., <br /> ESTIMATED CONSTRUCTION COST: -► and available options <br /> (Please round to nearest dollar) a/ 6°-o <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eyes [ lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Lives ❑j No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes 2No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es ❑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) E l v e s a ❑Don't know <br /> 7. Is this to correct a violation? Elves ENo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -+ -♦ <br />