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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 /> 3-O Se ON R: pp ✓Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> (,'7sc, 0 I d 1%3 Rd• <br /> Variance(# ) <br /> HOME PHONE 1 CELL PHONE E-MAIL ADDRESS <br /> C.08 si 3 78 10 [Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> N(4- rYip r Co•) Qv:��.v3 r T.'c • ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic tv/R <br /> P.n. adn 3 i c) <br /> (City,State,Zip) (Citty� T State,Zip) I 1 Setbacks <br /> OI r 6rT-G.J t 1 1 <br /> PHONE PHONE / ErSite Plan approval from <br /> 309— Z L 3^ 7 9 7q applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [✓]Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (h ttp://accessdane.co.dane.wi.us/) �✓"Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 1 frontage drawn to scale. <br /> NUMBER 0909 --1q3 -83 - I (�3Pic•6.vrC. A-I s{p <br /> TOWNSHIP: SECTION: <br /> V IC N u t°1 1/4: N W 1/a1/a: s`^/ ❑ Driveway permits N/ft <br /> ADDRESS: (state,county,town) <br /> 1 Ob 4 no t%3 Rot. N/A <br /> CSM: LOT SUBDIVISION BLOCK/LOT El Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: r, <br /> I i Z X SqS -Q1JS 1 <br /> LUL v. ❑ Zoning District <br /> . dThis project is a new building or structure. ❑ Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: �f PERMIT NUMBER: T ., s s a Cl Rural Address <br /> EWER �EPTIC 4 !rj r7 g` Alery"1/ (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not indudrng basement) <br /> 3-5 SC. 41 As ptG, , U 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: 1ST FLOOR: ❑ ErosionControl permit <br /> .361 3a j, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> i filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ NSA oO 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 6o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I 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) [Yes go ['Don't know <br /> 7. Is this to correct a violation? Elves o <br /> CC XS- 6 Pei I <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —4 -e. —0. <br /> 545-112(4/08) <br />