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ZONIN I. PERMIT APPLICATION www.counryofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM: <br /> I r DOT E Zoning Status; CUP; <br /> OWNER ADDR SS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> Zi D Wrl0 L,t6+ 1 Intal Ar7, W 16 764 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> 0 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> DOn /) 5 prtv►9 c1 e 1d [Site Plan includin location <br /> AGENT ADDRE•S CONTRACTOR ADDRESS ofwell/septic NIA <br /> I . i/. P <br /> (City,State.Zip) (City,ate,Zip) Setbacks <br /> Dole i e Gs )J 53521 <br /> PHONE PHONE []Site Plan approval from <br /> long° . 149"Ng 7 applicable township. <br /> E-MAIL ADORE'S E-MAILADDRESS <br /> 'town s )l l .5 bon ire ,t41.14 2 Floor plans to scale <br /> PROPERTY'LOCATION INFORMATION (http:/laccessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: [' Elevation of property <br /> PARCEL / �g t�� /� / �r�r frontage drawn to scale. <br /> NUMBER O90%D$0,8"-aS -el/95 e - 1 a 8.7 <br /> TOWNSHIP: SECTION: <br /> r f r c1 Q Id 1/4: $ E %%4: ,S [Driveway permits <br /> ADORES (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT -� n Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESSjtIPTION: <br /> VA.r' .5i )4e r ❑ 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 SERV CE: PERMIT NUMBER: ❑ Rural Address <br /> EWER FTEPTIC (new/existing) <br /> HEIGHT IN FEET: / OF STORIES: (Not including basement) <br /> /, / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: <br /> • ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 4/�� ❑ Review Location Survey <br /> ESTIMATED I O\ISTRUCTION COST: -0, and available options. <br /> (Please round to nearest dollar) $ <br /> 1. The prope is within 300 feet of a stream or 1000 feet from a pond or lake? QYes EINo []Don't know <br /> 2. Is there a etland or floodplain on or near the property? DYes 4 0 ['Don't know <br /> 3. Have you t;lked with the township about your project and are they in agreement? jYes II o <br /> 4. Has there •een a zoning permit issued for this property in the past 5 years? QYes No <br /> 5. Is this proj= t associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a locatio survey required? (see reverse) DYes QNo I Don't know <br /> 7. is this to c. recta violation? [Yes IgNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —0, .-■ <br />