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Gc) <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �j <br /> ', r46(_'" - 2E �`3-0 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 3 2 S_ 3 1/4 LL&1 ,1Af76 �v � Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 79 - ".Y3 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME l )114/49r< CONTRACTOR NAME <br /> 1-0 J, 7t F ❑ Site Plan including location <br /> AGENT ADDRESS �- CONTRACTOR ADDRESS / of well/septic <br /> r5nc 7?5 <br /> (City,Staatte,Zip) / (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> �J- / ''/ 7.0".. applicable township. <br /> E-MAIL ADD SS E-MAILADDRESS <br /> //A el (G,Ll /ti.71/41 (,ei l ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 6.4 U 5 /C4/4/5 1%: '/a'/a: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> Z SV V/-LLty J,P/O—Ai4 /0-P ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW ;.•PROJECT DESCRIPTION: / a t i <br /> 3C, 'Pl�ir�¢ ❑ Zoning liistncfry <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use1 <br /> ,,This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address s 3 <br /> El SEWER SEPTIC (/0ew/e Sng)31q1 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) r <br /> ❑ Wetlanef/Floodp(atn/ , <br /> Shbreland (attacbzn }� <br /> AREA TO NEAREST SQUARE FOOT: a <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErOSlon0optrolertntt <br /> 13 ZS6 4, TOTAL SQUARE FOOTAGE: j (slopes,i isturl ance, <br /> 2 D FLOOR: 3RD FLOOR: fi iingfeccessY � � <br /> ZS � <br /> ❑ Review Locatioti Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ /S DD D 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? ❑Yes ❑No ❑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? ❑Yes ®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) ❑Yes 0 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► -► -► <br />