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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AE <br /> tr,kZ --D'�9 r`(-IP\ ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> -1 t t 5 'orb Short -Pr• Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> 42.4 II ________ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> c>aN,h CV AlPAN A.COVIA.5 �,�,I��, CI Site Plan including location <br /> AGENT ADDRESS CONTRACTOF tss�p of well/septic <br /> w 323`b ttnw4.D.X 1 L___ <br /> (City,State,Zip) (City, ,Zip) ❑ Setbacks <br /> -?y..L.lL4.11l4 w13 5350% <br /> PHONE PHONE ❑ Site Plan approval from <br /> G—71,c C5 3(. applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> \ t,t-1 GAI, NA. (t;-4', \ ❑ 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 0 40 I D Ste_642r 4455-47 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: 1 1 1 ❑ Driveway permits <br /> rflamk,-I 34 A: w i4 4: M� (state,county,town) <br /> ADDRESS: ` c LL <br /> 7 1t5 NS or Tt, ` 1t. r • ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF RE EW <br /> PROJECT DESCRIPTION: a <br /> ❑:Zoning District <br /> . CI This project is a new building or structure. ❑ Permitted Use? <br /> project existing building or structure. <br /> ANITARIY SERVICE:t IS an addition/alteration to an P RIMI NUMBER: ,,Lt Rural AddCBSSaY R <br /> ❑SEWER ❑SEPTIC new/exlstig k <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) WetlancffPlood ! <br /> Shoreland (at tent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> Q ErostonEontAt��errnt 4�� <br /> BASEMENT 1ST FLOOR: 1 TOTAL SQUARE FOOTAGE: j (slopes l'disturb, nc g <br /> 2ND FLOOR: 3RD FLOOR: felling/aReP iri <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ --► ♦ and av ifable OptIOnB 3 <br /> (Please round to nearest dollar) ..l.. . ..pt <br /> 1. The roP e rtY is within 300 feet of a stream or 1000 feet from a pond or lake? IgYes CI No ❑Don't know <br /> P <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) D Yes lo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />