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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App <br /> ft <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1� <br /> S ILL V T ►"1 ESSE/_ II' Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) /� Deed Restriction; CSM <br /> 3'7 3 5 3KYH/6/-f I'D_ CO;Z-A(6‘ ve M. sic J variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS l <br /> 6C�'-a?/ i 8f� 3% Gv1�l i e.ie. b'S�te Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION I an{ includes dimensions <br /> AGENT NAME CONTRACTOR NAME J <br /> QGv61C7— Ei ' <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) <br /> Setbacks <br /> • <br /> j <br /> PHONE PHONE n Site Plan aprgval from <br /> applicab)township. <br /> E-MAILADDRESS E-MAIL ADDRESS // / <br /> n floor s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.whus/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT NIN? �J : ACREAGE: fronta a drawn,.to scale. <br /> ❑ li NUMBER O ��I J 1 `^ 1 <br /> TOWNSHIP: F� g s', <br /> . Cl-C 4 a �'��C SEC:( \ <br /> ,/4 ,// ❑ permits <br /> (sta)e,county,to ) <br /> ADDRESS: <br /> 3 7 g 5 Si<Yk/(L/ RD (&7—46.6 v4 Jo 5352 7 <br /> CSM: LOT SUBDIVISION BLOCK/LOT n Sanitarype �mits <br /> (pu , private) <br /> PROPOSED PROJECT INFORMATION a'`STAFF REVIEW <br /> PROJECT DESCRIPTIO : <br /> fD�&- /D,Ut 7-/cm/ © Zoning District <br /> . ❑This project is a new building or structure. ❑Permitted Use <br /> This project is an addition/alteration to an existing building or structure. r; �`i, <br /> SANITARY SERVICE: PERMIT NUMBER: r ❑ Rural Address, ; <br /> nSEWER [SEPTIC ,P (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> L / ❑ 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 /> /Q, / / 7' 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> c filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 3 74 <br /> 1 <br /> U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �JO and available options'. ii <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ -► $ 3o 000 <br /> 1 <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 /> I 2. Is there a wetland or floodplain on or near the property? ❑Yes El No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes [it 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 EINo n Don't know <br /> 7. Is this to correct a violation? ❑Yes NI No <br /> I 7c? O <br /> id APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -► -+ <br /> 545112(4/08) <br />