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I <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> .! <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> tinSS -ro V)v1 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 5) 3 k 7b w•err- Live, C,o,,d. , n'lot,rs kR,�. 1 Na---, S3�S y Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 64-6 SS 4965 60lf-z7-4-90,1 - ❑ 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-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARC NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER A 3 6 0g1A-a6y- s5 -a A.-I (Ex tfQ. 7- frontagedrawntoscale. <br /> TOWNSHIP: SECTION: <br /> [he-di in a. 1/4: 1�y4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 573w Tow-4-4- u,,,,- 12o,,,SL old fain-LGtevsc-- aktr.15 re-ass -l-o Newh'-w <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ' <br /> GhaKyc. 4'fu vst a1 old k , iv ay. R«cSS o,ri 6 v,ldlilj-(tJ ic4l ❑ Zoning Distnct t <br /> ❑This project is a new building or structure. <br /> • P J 9 � , <br /> ❑ Permitted Use9V <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ RuralAddress <br /> ew/existing} I ,' <br /> ❑SEWER ❑SEPTIC (� , { <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ WetlanloodplPtnf <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: 'g . - <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) '' z Oa <br /> 02 X Z Q SrostorfCot�tp � R is <br /> BASEMENT: 1ST FLOOR: (` <br /> ( / r ( 7 ( TOTAL SQUARE FOOTAGE: (slopes isturbdnce, <br /> 2 6 x �.L( 6 ><vi r it, tt i z fourlgTappo, "9 m <br /> 2ND FLOOR: 3RD FLOOR: <br /> 61 <br /> X -Li 1�� ❑ Review Locatio Surve <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and avalFab)`e 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 I No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I]1Io ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Les ❑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 Lio ❑Don't know <br /> 7. Is this to correct a violation? L"Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -► <br /> 545.112(4/08) <br />