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ZONIN PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER ' A <br /> O8� l� 7141/' ❑Zoning Status; CUP; <br /> OWNER ADD' S (Number,Street,Ci ,State,Zip) <br /> '' , �/�/ S5S fS Deed Variance Restriction; CSM <br /> � � ^ � MI �� '' (�( Variance(# ) <br /> HOME 1 CELL PHONE E-MAIL A'DRESS <br /> • Ce04 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> ADEN 0 /`�� � CON TOR NAME f7�jL <br /> AGENT ADDR ❑Site Plan including location <br /> W / /' ` R� /Lf CONTRA TOR DRESS of well/septic <br /> (Ci State,,,Zip (City,Stat ,Zip) <br /> Ill Setbacks <br /> • -. Z7/4,4, a".537/ -_-,n <br /> PHONE PHONE n Site Plan approval from <br /> 92.a Sp; Z - applicable township. <br /> E-MAIL ADDR: E-MAIL A.DRESS <br /> r E Li • , � 5 0 - -.., ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: n Elevation of property <br /> ❑PARCEL <br /> NUMBER <br /> E, j�3c�_ 9a >4 �� I frontage drawn to scale. <br /> Tjçi IP: -o SECTION <br /> PA-L.- - '/: 5V ,%,/: V ❑ Driveway permits <br /> ADDRESS: 7}�- (state, county,town) <br /> r ' " " ' 4 ' IJ?�' 111 Sanitary permits <br /> CSM: LOT SUBDIVIS ON BLOCK/LOT <br /> 0 rA / (public, private) <br /> PROPOSE(' PROJECT INFORMATION STAFF REVIEW <br /> PROJE�CTDES •TIO // <br /> �' ,'„al\ j` X.....::: -a .0+40 ❑ Zoning District <br /> MThis proje t is a new building or structur-. <br /> ❑ Permitted Use? <br /> ❑This proje t is an addition/alteration to an existing building or structure. <br /> SANITARY SERVI•E: PERMIT N MBER: Li Rural Address <br /> :EWERPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER.F STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUA-E FOOT: — Shoreland (attachment) <br /> (Outside dim.n-ions including unfinished area,attached gar:ges and above grade decks or porches) <br /> ❑ ErosionControl permit I - --,.....Z. -pgq_GA Big <br /> 2 s - 392 5/ 4 TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: �t 3RD FLOOR: f-7� ,/ filling/access) <br /> 4`5, -t >.. .C7 )z/1712 75 gi 501-( x...75> / /'`70 <br /> ❑ Review Location Survey <br /> ESTIMATED 'INSTRUCTION COST: and available options. <br /> (Please round t* nearest dollar) '♦ "♦ ♦ $ 2-2 /S <br /> 1. The prop is within 300 feet of a stream or 1000 eet from a pond or lake? ❑Yes f No ❑Don't know <br /> 2. Is there a ki:tland or floodplain on or near the property? Des No ❑Don't know <br /> 3. Have you tal ed with the township about your proje t and are they in agreement? Yes LINo <br /> 4. Has there b:en a zoning permit issued for this property in the past 5 years? ❑Yes EINo <br /> 5. Is this proje t associated with a rezone/CUP/varian.e(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) UYes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes �No <br /> 9.40 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />