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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME O <br /> OWNER ADDRESS (Number,Street,C�',State,Zip) <br /> 1❑ Zoning Status; CUP; <br /> LIS 6 j 5�4, /< (.y /.�,)' 0.--pc,,,, (,�/7 c-� )9 Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> :s©/-A S=/9SY Pc- -L./u L d„...4...9.,, e Y,A"y; C C •7" Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME I <br /> /)G /1 Gi' ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> PHONE PHONE ❑ S. e Plan approval from <br /> rlicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONI G: ACREAGE: In Elevation of property <br /> ❑ PARCEL 'ry /1'I frontage drawn to scale. <br /> NUMBER 05-Z./0V Og2— Y1/ . /) Y - I ' . z 3-2 <br /> TOWNSHIP: i SECTION: <br /> )�i k,t^ <br /> 8- S -/O 1/4: S r 1/41/4: r/cc, ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> r-/?6 5.-2-e I., /'ZI/41 Ce-PSirt w1 S-.-- r> l 1-1 Sanitary permits CSM: LOT SUBDIVISION BLOCK/LOT <br /> _ _ — ublic, private) <br /> PROPOSED PROJECT INFORMATION //STAFF REVIEW <br /> PROJECT DESCR TION: <br /> �' ��u u . •,i_ ' <br /> -' ti' / (( u Zoning District <br /> 0-This project is a new building or structure. L!T Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. �--�, <br /> SANITARY SERVICE: ,-- PERMIT NUMBER: ❑ Rural ddreS ' <br /> [SEWER nSEPTIC (new/ istin <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> cf 4 Pei —_ ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> J ErosionControl permit <br /> BASEMENT �_ 1ST FLOOR: Z <br /> I y 1 TOTAL SQUARE FOOTAGE: 1 (slopes;disturbance, <br /> filling/access) In <br /> 2ND FLOOR: 3RD FLOOR: .� Z <br /> �` \ <br /> ❑ Review Location Surve <br /> ESTIMATED CONSTRUCTION)COST: ♦ ♦ ♦ ♦ ♦ ♦ ..� and available options. <br /> Please round to nearest dollar <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes L^J No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? n Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? El Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes ❑No <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) ❑Yes ri No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes [ ]No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -p <br /> 545-112(4/08) <br />