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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 /> s'�v � '�cl oning <br /> OWNE DDRESS Number,,street,) 'ty,State,Zip) Status; CUP; <br /> a- ?c' K e Iles v ► s\� mi- teL \i aria Restriction; CSM <br /> ((��JJ�� / 1-4 �' Variance(# ) <br /> HO E PHONE CELL PHONE ILADDRESS <br /> ` 3 - LCSI• II - <br /> e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION aild includes dimensions <br /> AGENT NAME CONTRACTOR NAME NiSite Plan including location <br /> • . AGENT ADDRESS CONTRACTOR ADDRESS Of well/septic <br /> • (City,State,Zip) (City,State,Zip) <br /> ❑ Setbacks <br /> PHONE PHONE <br /> bite Plan a royal from <br /> Japplicab township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZONI G: ACREAGE: n Elevati0 f property <br /> ❑ PARCEL 0(06 ^ o(. /^ 5Q^ (�_ I 3 front a drawn to scale. <br /> NUMBER `7' ( ft <br /> TOWNSHIP: SE ON: , <br /> lci r ale /. SE. %1/: S F ❑ Drivew permits <br /> ADDRESS: (st , county,town) <br /> qa ? e ).e IIS \I S <br /> CSM: LOT S BDIVISION BLOCK/LOT H Sanita ermits <br /> ub' , private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> A e V.. Zoning District <br /> • ❑This project is a new building or structure. <br /> Permitted Use? <br /> ❑This project is an addition/alteration to an existing building of structure. <br /> SANITARY SERVICE: r PERMIT NUMBER: v\ l' —I Rural Address <br /> nSEWER �EPTIC (new/existing ) <br /> HEIGHT IN FEET: <br /> g NUMBER OF STO7ES: (Not including basement) <br /> J 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 /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: �/1 <br /> filling/access) <br /> rl`E,--'� .J Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) '°∎ —∎ --o• ' 1,. '- ' -r $ C?) 0 QC <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes l p4ja ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Et4 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes/ No/ <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave/blank' none) <br /> 6. Is a location survey required? (see reverse) ❑ . s o ❑Don't know <br /> 7. Is this to correct a violation? 'Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► -■ —' <br />