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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 /> / ii� <br /> � <br /> "4'� n <br /> � R 1 D Zoning Status; CUP; <br /> OWNER ADDRESS Number,Street,City.State.Zip) Deed Restriction; CSM <br /> as?7/ m t I/€r Rd (n/92.0)-7),94), W , 5354 Cl..) Variance(# ) <br /> HOME PHONE t CELL PHONE E�- °'ILADDR SS <br /> a`73,- 74-2-3136 C'6& ?7-e' ? 1SP rin 4 d' ' Nei- El Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ►VI&W S 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 0 , 'EbX i 2- <br /> (City.State.Zip) (.94.State.Zip) D Setbacks <br /> t c_ U GtI- 3.5LS <br /> PHONE PHONE D Site Plan approval from <br /> hoe -767- zyq applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> W I - _' 061 i eot14 D 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 /> DPARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION <br /> y4: /4,/: D Driveway permits <br /> ADDRESS (state, county,town) <br /> CSM LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 40( l/CPL) 7."'Z) RI S?' /4 ,1714L. ❑ Zoning District <br /> . ❑This project is a new building or structure. <br /> 0 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rural Address <br /> EWER [)EPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT; 1ST FLOOR: ❑ ErosionControl permit <br /> j, TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR 3RD FLOOR: 56 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► -► -► ♦ -► -► and available options. <br /> (Please round to nearest dollar) 1 Q0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Wes DNo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes No DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Wes DNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dyes EINo <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 0 o DDon't know <br /> 7. Is this to correct a violation? Elves n o <br /> /ir /' APPLICATION MUST BE SIGNED <br /> ' ( ,A 'jc[ U\VI` l T (Continul Back) -► -► -.r <br /> 545-112 14/08) <br /> (j i <br /> r VeA/4,, <br />