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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 /> '-'y C r <br /> n Zoning Status; CUP; <br /> OWNS DDRESS (Number,Stree,City,State,Zip) Deed Restriction; CSM <br /> M <br /> fc y ' y a ( /1 k,2,'" /to Varia nce <br /> (# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> cy- So,8Z S cW-e._ , I 1 Site Plan drawn to scale <br /> AGENT INFORMATION, CONTRACTOR INFORMATION and includes dimensions <br /> AGENT N E p CONTRA� NAME <br /> ^ pr <br /> (°), n Site Plan including location <br /> . AGENTADDRE CONTRACTOIR ADDRES of well/septic <br /> ?o/U- -S 0-4 0� 0 - & /(' u' ; (�'r' • <br /> (City,State,Zip) (City,State,Zip.) ❑ Setbacks <br /> PHONE PHONE _ Site Plan approval from <br /> �DO c, c O y 2 as_..., applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS n Floor plans to scale <br /> PROPERTY/L.4CATION INFORMATION (http://accessdane.r;,.dane.wi.us/) ` ❑ Elevation of property <br /> PARENT 40 PARCEL NUMBER: / ---- , • IN 4" ACREAGE: <br /> ❑ NUMBER ►re. .23 ,S j(+� Sf- /v EXC \_C-P y7 53_,j. frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> h ,/4: ¼¼: ❑ Driveway permits <br /> ADDRESS: // (state, county,town) <br /> ?6 -r-6. ot.�v1/`,rt>� n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION v`�" <br /> /6' xa(o vt �O / R <br /> cl j Zoning District <br /> ❑ This project is a new building or structure. U Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1 Rural Address <br /> FISEWER nSEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> / �/' I ❑ Wetland/Floodplain/ <br /> ! J ! Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 111 _C 3- \ L/l/ 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> l ` filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 3-61./ if( <br /> <r/I U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ' --► ♦ ♦ $ y p O O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes pi No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ,ifl No n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes 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) n Yes g No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'j No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ - —► <br /> 545-112 14/08) <br />