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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 /> SC LIAit 1 de.r. s `.,r - LLtL. ❑Zoning Status; CUP; <br /> 01AER ADDRESS (Number,Street,City,S e,Zip) Deed Restriction; CSM <br /> 40A �P2�_of //? (�tv" Gvi .35 Z Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> /ti ' _ `'`JS S - , ,_ --11 i <br /> Q LA- ^1,"9 •J171 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION C-send includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ,__16,,„ 2 , t'✓. It -c:,..-CcP•� (',r-... -4...r......,_S �$ �, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5vh.„.. 2._ • ry `7� S ct, ,<'cam 12) . <br /> (City,State,Zip) (City,State Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> 646- - 3(,_ �7(PO�/ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ... t........:.) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PNIURMCBEELR 066, " :c)Y4,0 S'' C Z .3,--> y frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> flh ,�' -c 'A: Set. %IA:sw ❑Driveway permits <br /> S (state,county,town) <br /> ADDR SS: �� �1 <br /> N ,`,,.-'••L4 r"-"/ <br /> 3,,,,k.t J ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW .; <br /> PROJECT DESCRIPTION: <br /> e •(-C S't-ry--�p Th.e. I: ❑ Zoning District <br /> . <br /> This project is a new building or structure. la Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: ,..iP PERMIT NUMBER: LI Rural Address <br /> EWER [EPTIC (new/existing) ;_ <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /(l Ce_ I I ❑ 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 FLOG ❑.ErosionCOntr01 permit <br /> I ` /St) 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> Mktg/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 7 Sv LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► -► -► -► -► O0, and available options. <br /> (Please round to nearest dollar) <br /> ...) ' ( F <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? Efres EINo ❑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 EDon't know <br /> 7. Is this to correct a violation? ❑Yes iTelo <br /> �Z / /ROD c `rte C S7 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) er (Continue on Back) <br /> II TiOt7 .&as E f E. <br />