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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Al°' ! .t'i Pc ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 1-41 V B c4 Je at. A4 d,ba'1 7/, �1— 3-)1( Varia nce nc Restriction;# CSM ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 2.Z2 , - q ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME vY /� CONTRACTOR NAME <br /> AGENTl I e A 6.6, El Site Plan including location <br /> S`ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /.20 Cti‘f '[5C be', <br /> (City,State,Zip) (City,Slate,Zip) ❑Setbacks <br /> PHONE PHONE ' ❑Site Plan approval from <br /> 3 S , /15(0 & applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: p p y <br /> ❑PARCEL ( �(�S2 q33�� 1 0 frontage drawn to scale. <br /> NUMBER , <br /> TOWNSHIP: SECTION: <br /> '/a: '/a'/a: - ❑Driveway permits <br /> �1 (state,county,town) <br /> ADDRESS: � <� / <br /> 4-4 , -.eckl//e- Jam.. /144d13 01 ['Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> '07.3`---7) � (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: l --hh > <br /> CC3Y/th-tc`� !�J� /12 X 24 /�e f J � 6 Ay f ❑ Zoning District <br /> . OThis 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: ❑ Rural Address <br /> DEWER IIEPl1C (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> -- ,c� ❑ Wetland/Floodplain/ <br /> i o 1 / Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) r--, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> !_. 3 -3 (Slopes,disturbance, <br /> + TOTAL SQUARE FOOTAGE: , <br /> 2ND FLOOR: 3RD FLOOR: Co,l filling/access) <br /> -- 3 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �1 /�' and available options. <br /> (Please round to nearest dollar) ♦ ♦ 11 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Bes 0 o Boni know <br /> 2. Is there a wetland or floodplain on or near the property? es 01 o on't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ekes FA o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ;2 o <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) es o Ikon't know <br /> 7. Is this to correct a violation? es o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> Sa5_11�(aim <br />