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ZONING PERMIT APPLICATION www.countyofdane.com F12211=1! <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AME ‘ <br /> DD( cOstifik C ���� ❑Zoning Status; CUP; <br /> OWNS`C�1 E (Number,gpr1 �treet,City�State,Zip) Ve( ` 3 9i Z V �(/_f�)}��/J� 1 J/� Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE I C L PHONE E-MAILADDRES <br /> El Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> NA <br /> eD(��c, (1iUCfu/Y) ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City/State,Zip)� ��� ���� ❑Setbacks <br /> PHONE PH\yONNE(/ll^/n` ❑Site Plan approval from <br /> (PO k- 14 Lj 4 -9(4 67 applicable township. <br /> E-MAIL ADDRESS E-MAIL ABDRSS <br /> --.5 �� � ❑Floor plans to scale <br /> c <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT Z NING: ACREAGE: <br /> ❑NUMBER UG 0.7 Z 5/ qq 3.-3 A- ( , frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> S,p{i'45 `‘e 2 S '/a: '/4%: ❑Driveway permits <br /> / l �a (state, county,town) <br /> ADDRESS: � <br /> ZO'Io cpii s £'3 Y (""�6(Piik ' ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> c Z 7. (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> F 1. $r u cc,--r -496,4A‘,/‘v - ❑ Zoning District <br /> - ®This project is a new building or structure. LI Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER VEPTIC (new/existing) <br /> HEIGHT IN FEET: ` NUMBER OF STORIES: (Not including basement) <br /> L S / ❑ 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 /> 2' 4, TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: b filling/access) <br /> Z s-(6, ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -0. 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 4o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Res Jo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes OjNo <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) Eyes 2 • ['Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -► -► <br /> 545-112(4/08) <br />