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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> N° rkle- 0 L/O her— c Hu A cs,1 <br /> ❑ Zoning Statu UP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ed Re ICtion; CSM <br /> 7 '(/ 4' G'Ay S' p.6 FD 14 140/. 7-- ,ii w(, aria e(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> B 3`-.2 6y/ 63° -/83 m Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1.3 c., 6 /-i/t RR t S C L 6.4 R y ?a h 1 'iro L c'an f'. ❑ Sit Ian including.location <br /> AGENT ADDRESS CONTRACTOR/ADDRESS of ell/septic A Qrk� <br /> ;735- M4yiLoi, o,c. C <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE ❑ Si Pl-• -pproval from <br /> -3 / -2 G ft( , able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) J Elevation property <br /> PARENT PARCEL NUMBER: CURRENT ZO NG: ACREAGE: P P y <br /> ❑ NUMBER ©?�"06 I `©Q p- a v f on of <br /> �2 y f frontage drawn t Cale. <br /> TOWNSHIP: SECT: <br /> M ( o C �G v) 1/4: N 1/41/: NE ❑ Drivew permits <br /> ADDRESS: s ,county,t. n) <br /> 7y, y w/qys.ve RD <br /> ❑ Sanit. permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (p ,� ic,private) <br /> &SonriicnN L1 i4/ <br /> PROPOSED PROJECT INFORMATION STAFF`REVIEW <br /> PROJECT DESCRIPTION: a <br /> 2 C x V/ Pt'i 8u/ Div6, foe g-cpu/' -1-- ° nin District <br /> 9 .0 <br /> . ®This project is a new building or structure. ,.ermitted Use? <br /> ❑This proje t is an addition/alteration to an existing building or structure. <br /> SANITARY SERV E: PERMIT NUMBER: ❑ Rural Arr" <br /> SEWER ❑SEPTIC (new/ x sting (' <br /> HEIGHT IN FEET: I ( NUMBER OF TORIES: (Not including basement) <br /> ❑ Wetla iodplain/ <br /> Shor nd (attach AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached arages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErpSIOnG z rot r ieg=- to <br /> C f 1 TOTAL SQUARE FOOTAGE: (slop s d sturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filliing/access) <br /> ❑ Review Location Survey/ n <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ ♦ --► ♦ $ / dd afit available OptiQnS <br /> (Please round to nearest dollar) 3�✓ 3 ,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,allo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes $No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 4Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ,®Yes ❑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) UYes allo ❑Don't know <br /> 7. Is this to correct a violation? UYes ,.No <br /> A ec ---- APPLICATION MUST BE SIGNED <br /> 545-112(4/08) , <br /> (Continue on Back) - -► -► <br />