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RH / <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 010.VER NAME <br /> Dean 1r{ Y9d /&tea SIT tAm,15 ❑Zoning Status; CUP; <br /> O�NERAD ESS� er treet,City,1C. ,Zip) <br /> ��JJ[[``�I��''�� IIC!_ Ne,,4, Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 007'-7!0(4-a-5I 01; ..D..0-17) ! ❑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.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 61 I p�`/} /i <br /> 7 3+-/`�D 1 r-l ( 3..1C- frontage drawn to scale. . <br /> TOWNSHIP: SECTION: <br /> P.2-s-ejeI 2-cl 1/4: 54) Y/<. ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> -5qq S-03. - 4-1c- a ❑Sanitary permits <br /> CSM; LOT SUBDIVISION BLOCK/LOT <br /> I ,f / f; f (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> P JE T DESCRIPTION: <br /> ro yl - ►-€ o)�c 1 n3 C_.li y - ❑ Zoning District <br /> - his project is a new building or structure. <br /> ❑ Permitted Use'. <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER rEPTIC �_ (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 D . 15 \ ❑ Wetland/Floodplainl <br /> Shoreiand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) a <br /> BASEMENT: 1ST FLOOR: ❑ trosionCOntrol-permit <br /> I S-0,0 4, TOTAL SQUARE FOOTAGE: ,, „-(slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> 1 S o 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> .� -0 .+ -0. .� "and available options. <br /> (Please round to nearest dollar) $ �O I 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves Rio ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves 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 ZiNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blanlyif none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? [Yes ,23No <br /> 61Z/2_0 Z 4 <br /> A(Continue PPLICATION on Back) ♦MUST BE SIGNED-0 <br /> 545-112(4108) <br /> —o <br />