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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME A. <br /> dor • i�/f? �_iri O)4 <br /> /de)0 C►_ oam�= <br /> ❑ Zoning Status; <br /> OWNER ADDRESS (N er,Street,City,State,Zip)A • I <br /> Ll Yl Arr � � �j y , ` Deed Re ion; CSM <br /> CCl�- s7 ��- �- � /...�lllii� E'er j��'. t:.� � i / Vari e(# ) <br /> HO E PHONE CELL PHONE E-MAIL ADDRESS <br /> JC ' /2o A Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CON TR .CTOR NAME <br /> 2 /ce/i� 5- <br /> , ,,// i Site Plan including location <br /> AGENT ADDRESS CONTRACTORADDRE,SS ,� f well/septic <br /> �� �"/�!/>. /-° A'y'r 2 C(— <br /> (City,State,Zip) _ Setbacks <br /> (City,State,Zip) / %r��' <br /> //a 6../. —6),_ S > <br /> PHONE PHONE _ ❑ Site Plan royal from <br /> 2 % Q (9c2 / C� pli le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> ❑ PARCEL G ,� if :`g)CJ_ fe..._ i.� I frontage drawn to scale. <br /> NUMBER �' <br /> TOWNSHIP: SECTION:61;4 1 6/A e 1414;12/A.2_ 1414: S L.:: ❑ Drivewa rmits <br /> ADDR j M (stat ,county,town) <br /> I 1 ` <br /> �I S'e C_'1 ' ❑ Sanitary <br /> mits <br /> CSM: LOT BDIVISION BLOCK/LOT ry <br /> t4 Li- y (publ' , private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D SC'IPTI y `. I J a r <br /> I ` • I ^ `I ( 16 t'1 lZpning District <br /> . ❑This project is a new building or structure. Tr -).d- -)y $ C G{' "u permitted Use? <br /> J This project is an additiLIC teration to an existing building or structure. <br /> Adtess\ <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural qe /existing�i' <br /> ❑SEWER Q --- \ N <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) 1 \js <br /> / I.( 4!Wetland/Floodplain/ ,j, <br /> 7horeland (attachment)AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) i permit U� <br /> BASEMENT: 1ST FLOOR: Id ErosionControl <br /> � <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) Cc( ( ( <br /> 2ND FLOOR: 3RD FLOOR: CCV//\�� 7 <br /> ❑ Revi9Artocation Survey ,.- <br /> ESTIMATED CONSTRUCTION COST: Q an available options. <br /> (Please round to nearest dollar) "♦ ♦ ♦ ♦ ♦ ♦ $ . ) 0© O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? @ es ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? % Yes ❑D4o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes FU <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// none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> N .1 0U APPLICATION MUST BE SIGNED <br /> / (Continue on Back) —► -* —► <br /> 545.112(4/08) <br />