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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM �� <br /> �"'a-i/ '' /I ' '/S n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ,,200 7pl,em hac7t,/7 fi,' <br /> i� S'3 S �3 Variance(# ) <br /> HOME PHONE CELHONE E-MAIL DRESS <br /> Site Plan drawn to scale <br /> AGENT INFORMATION I 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,Stale,Zip) Ti Setbacks <br /> PHONE PHONE n Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CUR E ZONING: ACREAGE: n Elevation of property <br /> ri PARCEL NUMBER ULL .tO p�$H 1)S .57a frontage drawn to scale. <br /> TOWNSHIP: SECTIa <br /> 16-4-13 a (0—�IA: IAIA. n Driveway permits <br /> ADDRESS: (state, county,town) <br /> 0 9 (T\ \-\Akkorn Or- v o() p}- L S35-53 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 00.14. ShQ Ck ❑ Zoning District <br /> . Y(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 NUMBER: ❑ Rural Address <br /> SEWER 154EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> C, ❑ 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 /> •)��C 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ,20 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ ♦ _► ♦ `i/J` and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ,Yes `,1No LDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes fNo ',Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes I No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? _Y- es KNo <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) Y- es No DDon't know <br /> 7. Is this to correct a violation? EYes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(4/08) <br /> LOC <br />