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ZONIN 1 PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AM _ <br /> S e = 0,A4 , un`I Co++'-e II ❑Zoning Status; CUP; <br /> OWNER ADD' . (Number,Street,Cit State,Zip) Deed Restriction; CSM <br /> 71.15 ' e0/�J3ELL P///Ee u/Uuo �oa c/RESS eran 4, Pc)/ 53543 Variance(# ) <br /> HOME PHON: <br /> tio; -8y' x699 cog 16-9W6 Sue7955 (d -#7Gi1' «7) Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Cl ea/ y 6 kkt 1 J ny S ❑Site Plan including location <br /> AGENT ADDR ' CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip (City,State,Zip) % C�5 3 El Setbacks <br /> Vecmct, W <br /> PHONE PHONE ❑Site Plan approval from <br /> 608 p <br /> - 0 y 5 - 760 applicable township. <br /> E-MAIL ADDR: ` E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 1=1 Elevation of property <br /> PARENT PARCEL NUMBER: 9 CUR EN ZO ING: ACREAGE <br /> ❑NUMBE 01008 06/- / co `i-1%k II- 1 1 , 19 frontage drawn to scale. <br /> TOWNSHIP' SECTION: <br /> V• '/.: '/a'/a: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DE' !IPTION: a <br /> a7 r m e G-or,.�,O ❑ Zoning District <br /> . [This p is a new building or structure. !] permitted use? <br /> ['This p is an addition/alteration to an existing building or structure. <br /> SANITARY SE : PERMIT NUMBER: 0 Rural Address <br /> -EWER EPTIC (new/existing) <br /> HEIGHT IN FE T: NUMBER OF STORIES: (Not including basement) <br /> ,,,,t_ I I ❑_Wettand/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside di e sions including unfinished area,attached garages and above grade decks or porches) <br /> a ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 0 4, TOTAL SQUARE FOOTAGE: (slopes,dts rbance, <br /> - filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> II ❑ Review Location Survey <br /> ESTIMATE II I ONSTRUCTION COST: $ 1-7� and available options. <br /> --0.(Please ro nd to nearest dollar) -- ♦ -o. <br /> / <br /> 1. The pro,.e y is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 04No ❑Don't know <br /> 2. Is there : etland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have yo t:Iked with the township about your project and are they in agreement? Sfres DNo <br /> 4. Has the e teen a zoning permit issued for this property in the past 5 years? ❑Yes Silo <br /> 5. Is this p •j:ct associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a loc- io survey required? (see reverse) (Yes Jlo ❑Don't know <br /> 7. Is this t•',c•rrect a violation? ❑Yes Mlo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► <br /> 545-112(4/08) <br />