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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 7 5 w/r 'Q ( Mt -4./' 'Z 5.-33--5" Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Q Z- /L - 7w /uj, zc 40 P�,-, ,A--S ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ 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-MAIL ADDRESS <br /> ❑ 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 /> ja PARCEL D(�i p_ pq 3 -O193 h°- <br /> NUMBER 3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> r9 v 11V d 0 0I 5014: Ai►-. 1/4'/a: ❑ Driveway permits <br /> /d <br /> ADDRESS: �- (state,county,town) <br /> 2 76 't'- ' V A 7c/ / wT S 3 SAY <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> Z3 Gpe",ril/ &� 2 23 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �` i s <br /> pci-Jrb ❑ Zaning Districvl <br /> . ,aThis project is a new building or structure. r <br /> ❑ Permitted Usez <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Q Rural Address <br /> ❑SEWER ❑SEPTIC (new/exis"tint, <br /> a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) l r "V: <br /> Sh'oreland(attac im ) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ 4rosrp€�Citrg "errrit <br /> BASEMENT 1ST FLOOR: �„ 5��� , <br /> 4, TOTAL SQUARE FOOTAGE: $, (Slopes,disturbance, , <br /> 2ND FLOOR: 3RD FLOOR: �� fulling/access) 10 <br /> ( .5 _ ? F <br /> ❑ Review LOCatiOn*O - <br /> ESTIMATED CONSTRUCTION COST --► -i 7o oo and available eoptions <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? ff-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? 'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Flo <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 ❑No <br /> a <br /> /O V ' O 17 APPLICATION MUST BE SIGNED <br /> ° (Continue on Back) -. -* -► <br /> 545-112(4/08) / <br />