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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 /> 1 ,- <br /> b sa Iv \ C L. �vi o 11 tf i-R El Zoning Status; CUP; <br /> OWNER ADDRESS (Number,S t,City,State,Zip) Deed Restriction; CSM <br /> D 1A w 1< IA r1bt�L,'t�0 t�S W ■ S3 54 e� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> O 3 v " i a�o ,.` "e.- 1 433 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) ❑ Elevation of property <br /> PARENT PAR ES�L NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER JJ v V O -Z?3-g s t-o —1 0 , 3 S7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 5 \ )(,V 1 K L X , 1/a: 1/a1/a: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 1 l 0 S C ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> i:_ r ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> V'his project is an addition/alteration to an existing building or structure. <br /> S NITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER EPTIC (new/existing) <br /> HEIGHT IN \^_ I l NUMBER OF STORIES: (Not including basement) <br /> s 11C� ❑ Wetland/F000dplain/ <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: ❑ <br /> ErosionControl permit <br /> 1, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> . ❑ Review Location Survey <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 ,/No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />