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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ji <br /> M-ite., / .Lt)Q?'L ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Nu Aber,Street,City,State,Zip) Deed Restriction; CSM <br /> v(aS 0/yE-<<J� (�) ��90(Lc-y/0 id! Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR SS <br /> /J ,4- OF --a o 4 /I _ t<J 72 7 e 4 Noo - Co/✓( ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ,s'e /C £- , ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wt us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL BER 85a G ►a ^3c3 0 4�- a- I ,73 S frontage drawn to scale. <br /> TOWNSHIP: SECTION: 4° <br /> e ❑ Driveway permits� ),)0 30 14: 1,41x: > <br /> ADDRESS: n p (state,county,town) <br /> 360" Y 47 <br /> 6l/ /1,00/Le'y J t W/ ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF R1 VIEllli! <br /> PROJECT DESCRIPTION: <br /> Do - i-t o (:)h7t AT ❑ Zoning District <br /> . WI-his project is a new building or structure. ❑:Permitted Use? <br /> ❑This project is an addition/alteration to an existing buildi „„ng or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address 4 <br /> ❑SEWER SEPTIC (new/exiSting)� t l <br /> Pn(a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> t� ❑�,Wetlan i0:040pl4i,f►l <br /> i <br /> y Shorelar d (attac ment) <br /> AREA TO NEAREST SQUARE FOOT: £ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErostonCont>•al 7)ermlf <br /> BASEMENT: 1ST FLOOR: <br /> ,, TOTAL SQUARE FOOTAGE: ,` (Slopes,disturbance ' <br /> /a ° fillingfac ess) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3 <br /> /o`/o ❑ Review Location SurveY <br /> ESTIMATED CONSTRUCTION COST: 'and available Options q <br /> (Please round to nearest dollar) "� ♦ ♦ ♦ ♦ --► J3 OZrU ... <br /> f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? caYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes pNo <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 Al No <br /> X0, APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -;► -► <br /> 545-112(4/08) <br />