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I. ■ <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION cam( 1 CUSTOMER TO PRO V E <br /> • OWNVII P€AiX Vv \ ` ��1�\ �' ; <br /> Zoning Status; CUP, <br /> OWNER ADDRESS (Number;Street,'Cit�y,�State.,Z,ip) Deed Restriction; CSM <br /> 5.. ....1 \ J IN Q e� ��� Variance(# ) <br /> HOM PHONE CELL PHONE p� E-MAIL ADDRESS 51-3 <br /> a . ' co(-cc, N Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME A , _ / f � 0 CONTRACTOR NAME <br /> `y / 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> � 3 0 f <br /> / <br /> (City,State,Zip) (City,State,Zip) Setbacks r i <br /> PHONE PHONE tg.Site Plan approval from A <br /> applicable township. <br /> E-M ADDRESS E-MAIL ADDRESS <br /> 4-Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT Z NIN ACREAGE: l Elevation of property <br /> 0 PARCEL NUMBER 1 1 ". 4 -.4'7, —� • LH frontage drawn to scale. <br /> TOWNSHIP: C SECTIO : �� O <br /> ro�c1 O N C(ur�� I d 1/4: 1/41/4: IN Driveway permits <br /> ADDRESS: (state,county, • 1 <br /> 5151 1N-)a• 0� ,� <br /> CSM: LOT SUBDIVISION BLOCK/LOT (Sanitary•- �� is <br /> \w (public, glp <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION a , <br /> ix x 1 o' Zoning District <br /> I <br /> pi project is a new building or structure. ❑ Permitted Use? //i ?�❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural ' -.,■- <br /> EWER [EPTIC (new. <br /> =I?Q�•� <br /> HEIGHT IN FEET:q J I 1 NUMBER OF STORIEot including basement) <br /> Li— tgf A - •odplain/ <br /> horeland -ttachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r <br /> BASEMENT: 1ST FLOOR: X11-crosionContrOl permit �/' jt <br /> j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, �(t w <br /> 2ND FLOOR: 3RD FLOOR: <br /> Ifilling/access) <br /> dO O. 0.0 "Review Location Survey r <br /> ESTIMATED lease round CONSTRUCTION nearest dollar)COST: ♦ ♦ ♦ ♦ $ I 1 g 1 �� 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? Dies eI to Don't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes ;12Rlo DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Des ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies ,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) ElYes DNo DDon't know <br /> 7. Is this to correct a violation? [Yes �f'o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(8/09) (Continue on Back) - -+ <br />