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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 /> Dail J- e fa t.t. PL_1-1-,,,,ti- ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Stat,City,State,Zip) Deed Restriction; CSM <br /> 06? ' -ih 4,s Pd / 2,07,0 1n' Dom,c VI 6.--G 0 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1l- 14 CO etti, <br /> yn �� ix ri ❑Site Plan including location <br /> AGENT AD V of well/septic� I 6.o L t.' -tom <br /> (City,State,Zip) (City,State,Zip ^K//T/ ❑Setbacks <br /> S l9� K G' ,'ta I,ur c35-0 <br /> PHONE PHONE ❑Site Plan approval from <br /> 60T-- (,,L - 644.3 9 applicable township. <br /> E-MAIL nADDRESS a" k; pCt` E-MAIL ADDRESS <br /> Gf• A • I L I. •.Cow) ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.ce-dame-wi.us/) <br /> PARENT PARCEL NUMBER: CURREN O I G: ACREAGE: ❑Elevation of property <br /> ❑PARCEL q ' — frontage drawn to scale. <br /> NUMBER 054/be C7 7-0&P- 13°t�� r 00+� <br /> TOWNSHIP: SECTIOIJ: ng� "°7 r 0- <br /> 6 F d v, 3..!.7tht'rrg,1/4: it) '/a'/a: ❑Driveway permits <br /> ADDRESS: <br /> 7 (state, county,town) <br /> Ili S./"S ed /I2/ 0r .4-f?t` cuC 5'3 <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> °e 7 3/ / (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE T DE RIPTION: /�. <br /> roor►� (Ad;4r°o`'1 ❑ 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. <br /> SANITARY SERVICE: PERMIT UMBER: ❑ Rural Address <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET / '' /' NUMBER OF STORIES: (Not including basement) <br /> /3 a 1r / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached gal-ages and above grade decks or porches) <br /> BASEMENT:, j/ 1ST FLOOR: ❑ ErosionControl permit <br /> /43 (G■/(x%' ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> �❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ,_ /! :) /I .v and available options. <br /> (Please round to nearest dollar) $ / Loi <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes "lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves Slo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes 'lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes C to <br /> 5. Is this project associated with a rezone/CUP/variancce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes Jlo ['Don't know <br /> 7. Is this to correct a violation? ❑yeslo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />