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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 /> �,t e 0 A;(4 7 er J 4 vl 61( ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Q \ „ ;Sk �c /1'i<✓` S`Li4 V( Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br />' it— 2 h. ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACT R NAME <br /> a n Vc lam- ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3Ci 00 1414✓ r 138 <br /> (City,State,Zip) (City,State,Zip) / / ❑ Setbacks <br /> 970 t1C 4avt W: s3Vi <br /> PHONE PHONE tJ ❑ Site Plan approval from <br /> ‘°6 _ g93 9 yS y applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Cc' ZS S - /00 0 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL ,� /C �, frontage drawn to scale. <br /> C; <br /> NUMBER ci L- • 15/ -9-C S <br /> TOWNSHIP: SECTION: <br /> 1/a: 1414: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . ar This project is a rfeew build' _• •r structure. ❑ Permitted Use? <br /> ItThis project is a addition/- -ration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> i/ Li Wetland/Floodplain/ <br /> //' / Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 1 TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> l�r 01"--€.-- / 7X /3 filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> U _ /� v _ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ --► $ 2 )_ ell./ 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? aYes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes LNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -+ <br /> 545-112(4/08) <br />