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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 /> 7Jh S 1--nUt54ra-'t`A4s L.L.0 [`"Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> (i U C c 09) Co.0 4--rr VE,la^C.l, wr y.?S 13 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> i 1+114-61 c 55 TES ET E Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ✓ <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) W j (City,State,Zip) Setbacks <br /> PHONE PHONE Site Plan <br /> approva l <br /> from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Q Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> DPARCEL PARENT PARCEL NUMBER: / `\ CURRENT ZONING: ACREAGE: Elt <br /> NUMBER 017.5,/Q5-( —l8r'/( V Ar'—ZC I) /. ��a aG frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /V -f-6 a Y.: 5f 174 4_ Nz Er-Driveway permits <br /> ADDRESS: (state,county,town) <br /> 77 Z j A S-3CO� /Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> t .344 + (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIOy <br /> /Lieu .) 6p ra%...t2 ❑ Zoning District <br /> . EgThis project is a new building or structure. <br /> ❑ Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEVVER EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /S ( ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> IF TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 57/ filling/access) <br /> (0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ i -► ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ /O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes [4io ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Oyes o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes �Vo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ®Yes DIN 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) Oyes ,�Vo ODon't know <br /> 7. Is this to correct a violation? Oyes Eflo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -* <br /> 545-112(4/08) <br />