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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU •TOMER TO PROVIDE <br /> OWNER N <br /> I �'� 6L,1° `I Zo ng Status; CUP; <br /> OWNERAD SS (Number,Street,City,State,Zip) , 11 ed Restriction; CSM <br /> I ct?W !t5he ✓'A c5f v�itn,1l, W. .5`�3S�y ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR S j( 0 • c o AA, <br /> i 1 -l , -17, I b. c co,- Q ,L;ass ,� 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-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARK LNUMB R: Q (� CU RENTZONING:t ACREA E: <br /> ❑NUMBER © I (�"O� - / x I Q� frontage drawn to scale. <br /> TOWNSHI SE 10 <br /> %: / �'a'/a: `S \) ❑ Driveway permits <br /> ADDRESS: <br /> ""�K� ''` (state, county,town) <br /> 19 7' 1 G 5 I i 4. r J ❑Sanitary permits <br /> CSM: co LOT SUBDIVISION BLOCK/LOT <br /> • <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW' <br /> PROJECT ESCRIPTION: <br /> ��; L 1,;1 P1ti,3 do,IL- 7a.1 CL Pill CA ,�, ❑ Zoning District <br /> . ['This pro ect is a new buildin r struct k. f <br /> Permitted Use? <br /> This project is an additio Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES:,(Not including basement) <br /> /0 ( ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 0 filling/access) <br /> /.% '' 6-60 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ ♦ ♦ and available options. <br /> ♦ <br /> (Please round to nearest dollar) $ eg 6 5-0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Is ❑'No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Peso <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) Elves Vo ['Don't know <br /> 7. Is this to correct a violation? DYes No <br /> t ^` APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -► <br /> c—i°545-112(4/08) <br />