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' V 1 <br /> 1 <br /> ZONING PERMIT APPLICATION .countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ?EP,1, / /42:-.4 G///c / �v Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> I,"92 //U/�/. /+'�o , /2 // '' , 4/ ;/" r2z Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILAD•-ESS <br /> 3S 0o3`i .14..- /j'e/CJS,/2 I• -ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRAC OR NAM <br /> (Site Plan including location <br /> AGENT ADDR CONTRAC •R ADDRESS "'of well/septic <br /> (City,State,ZF) (City,State, P) Setbacks <br /> PHONE PHONE _ @ n oval from <br /> appli township. <br /> E-MAIL ADDRESS E-MAIL AD'-ESS <br /> 03 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT•ONING: ACREAGE: Elevation of property <br /> ❑PARCEL a drawn to scale. <br /> NUMBER if), /f'Z 91 /r/ E91 <br /> g <br /> TOWNSHIP: SECTION: <br /> /�I/,G',0/ G'� Ub %.: 4/4- ,/<'/4:5Y'� ❑Driat� c u ermits <br /> ADDRESS: (st nty,town) <br /> e\/7 <br /> CSM: LOT 9� SUB IVIS ON BLOCK/LOT ❑Sanl rmits <br /> �y ION (publi • ate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /2 k/1" G(.7-/ -/2Z -rife/) pyoning District <br /> . NThis project is a new building or structure. ermitted Use? <br /> This project is an addition/alteration to an existing ouilding or structure. <br /> SANITARY SERVICE: PERMIT NU BER: Rural Ad. - <br /> EWER TIEPTIC (new (sting <br /> HEIGHT IN FEET: NUMBER O-STORIES: (Not including basement) <br /> 9/(1 A J 1 i tl to plain/ <br /> S /\Shorettachment) <br /> AREA TO NEAREST SQUAR: FOOT: 11 <br /> (Outside dimensions including unfinished area,attached gara•es and above grade decks or porches) roS o permit <br /> BASEMENT: 1ST FLOOR: �- <br /> "/ ' + TOTAL SQUARE FOOTAGE: + (SIOpe tUrbanCe, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filli acts s) <br /> /'#'/ - -Review tion Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ Q ��) \and dab! options. <br /> (Please round to nearest dollar) �V V <br /> 1. The property is within 300 feet of a stream or 1000 f:et from a pond or lake? ❑Yes ,ZiJ 'o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the prope y? [Yes ca o ['Don't know <br /> 3. Have you talked with the township about your proje and are they in agreement? l(es • o <br /> 4. Has there been a zoning permit issued for this prope y in the past 5 years? [Yes EiNo <br /> 5. Is this project associated with a rezone/CUP/variant: (petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes .; o [Don't know <br /> 7. Is this to correct a violation? [Yes IT/ o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(8/09) <br />