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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT#o Web•App.#' <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> r t( en G ©U c n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �" ( Deed Restriction; CSM <br /> 16 as Tfgi(S .End /"l Qdr4.1/ WI SiS 6 ? Variance(# ) <br /> HOME PHONE CELL PHONE / E-MAIL ADDRESS <br /> adg-537- 79P 6 303-%37- 6c13( coact, i77 Q MG,* • ce,"^ n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION: <br /> and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> I Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) n Setbacks <br /> PHONE PHONE n Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> . ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.4ane.wi.us/) n Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ZONING: O ,CREAG <br /> I[1 PARCEL (n��CC�� O Z frontage drawn to scale. <br /> ' NUMBER 0 C1�0 8 l -12 H -6 9 v 7 g., 1 $ <br /> TOWNSHIP: /// SECTION: <br /> s —a V ac. cov Pr.( �>, I .. 1/4: 1/41/4: ❑ Driveway permits <br /> J h (state, county,town) <br /> ADDRESS: ( In _ <br /> 16Z —rep►(s Ed i"1grrLai) �1 Si 3q n Sanitary permits <br /> CSM: LOT 1I i SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DES RIPTION: p <br /> r9 a c e, oVetL J Zoning District <br /> . ❑ This project is a new building or structure. J Permitted Use? <br /> aThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1 Rural Address <br /> [SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: ►/ NUMBER OF STORIES: (Not including basement) <br /> a .fi-- i U 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 /> 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: - <br /> 6 Ni U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: U and available options. :_ <br /> (Please round to nearest dollar) --► - - --► 3 © ©0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 12 No n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? El Yes n No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes X1 No <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) n Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ?E No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ —► <br /> 545-112(4/08) <br />