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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 /> L. =' tea-✓- r.. ❑ Zoning Status. P; <br /> OWNER ADDRESS (N er,�Street,City,State,Zip)r e Deed Re • ion; CSM <br /> ,..5-1/ ll / �? - P /�`�✓'!���ic� �' �". < ',, j •Var' e(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> • -S� '.� A S'te Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRCTOR f AME <br /> 2,r)(,'P/' --,-7 / t S. Plan including location <br /> AGENT ADDRESS CONTRA CTOR ADD DRES well/septic <br /> ,1 <br /> VelCT/tr 4.--_ <br /> &y'c 2 CL <br /> (City,State,Zip) (City,State,Zip) // Setbacks <br /> %9a <br /> {,�i, �& /6) -?.!:C <br /> PHONE PHONE ❑ Site Plan royal from <br /> 2 j Q - 0 0 j C) ppl. le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: Q CURRENT ZONING: ACREAGE: p p y <br /> ❑ NUMBER G�i- 7a9�/�,'C)'-3 �"` 1 �, frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> • <br /> �� 1 _/ ) 1�41�: S i ❑ Driveway permits <br /> ADD) �r /' ; /4 (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT BDIVISION BLOCK/LOT <br /> t J(0a-u 0 7 62,- ` (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> P-OJECT D SC'IPTI it: <br /> 46-----z- _.....�s t U C� ) T1\ ' c)) 6.‘ ` P, I 101n ❑ Zoning District <br /> . ❑This project is a new building or structure. „ a y $ ` ' <br /> Permitted Use? <br /> 14 This project is an addition/ Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: CI Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET /� NUMBER OF STORIES: (Not including basement) <br /> 9 / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: iSTFLOOR: ❑ ErosionControl permit <br /> j, TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> filling/access)il <br /> 2ND FLOOR: 3RD FLOOR: ���JJJVVV CD <br /> . D Li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: I ['0 0 and available options. <br /> (Please round to nearest dollar) ♦ ♦ --► --► --► .. <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes i ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blan if one) <br /> 6. Is a location survey required? (see reverse) Li Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> rs <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► - . <br /> 545-112(4/08) <br />