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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> oWNE M° <br /> - \I fs 1 gAs iL A N11 c.,01.16N2L ‘ ( CI Zoning Status; CUP; <br /> OWNER ADDRESS (Number,St et, ity,State,Zip) / Deed Restriction; CSM <br /> Q c_ CD. Variance(# ) <br /> ROME PHONE CELL PHONE E-MAIL ADDRESS <br /> Z-0/-0 5 3 Z ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME C• CTOR NAME <br /> r,/ 14O/A/6 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A ESS of well/septic <br /> /Z33 ./4,7wAoe>c -/- <br /> i ❑(City,State,Zip) (cSta )Zip) Setbacks <br /> "I, ..3Sg 9 ❑PHO N E PHO E Site Plan <br /> approval from <br /> 7 3 — 193 S'- applicable township. <br /> E-MAILADDRESS E-NIAIL ADD- SS <br /> d-_. . . d r ii-- ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZ NING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 05 J/-// 7 _ S.Wy0`z_ J ki — L . 9 frontage drawn to scale. <br /> NUMBER / (D G. Pf" 6 <br /> TOWNSHIP: SECTION: <br /> t.Q 14: N IIJ 1/a1/a: ❑ Driveway permits <br /> ADDRESS: I 1 (state,county,town) <br /> I Os- 3 C0. c:).. (\ 0 U6 h�D NI ❑ Sanitary permits <br /> CSM: LOT / SUBDIVISION BLOCK/LOT <br /> gr (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D RIPTION: 'a <br /> � � ie L ❑ onrng, tisinct w <br /> . <br /> 61 <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> P J ❑ Rural Address �4 <br /> SANITARY SERVICE: PERMIT NUMBER: :g <br /> (neW/existing)" <br /> ❑SEWER SEPTIC 3 <br /> HEIGHT IN FEET: NUMBER r STORIES: (Not including basement) <br /> I ❑ Wetland/Fivod{lain/* � t <br /> AREA TO NEAREST SQUARE FOOT: ' ShQrelcfhd 40-#1 ,:t t} <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ E3rosionControl permit <br /> BASEMENT: 1ST FLOOR: i V <br /> j TOTAL SQUARE FOOTAGE: j, (slopes,disturbance :,� <br /> flying/access) <br /> 2ND FLOOR: 3RD FLOOR: Z t.1� �,, <br /> T �� ca <br /> ❑',Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and avaiiabteoptioi�s <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 DINo Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Z,No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes tgl No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ININo <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) %Yes ❑No ❑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 />