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• 1 0 ,if <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O A NER NAME <br /> 9_ <br /> Ar--e, ` _ / M oning Status;CUP; <br /> OWN R •DDRESS (Nu . r,Streette,State,-ip) Seed Restriction; CSM <br /> ® c \l N/ iV 1 <br /> Variance(# ) <br /> ROM�E PE C L PHON E-MAIL DDRESS <br /> Ct ! Y' 2N . -, <br /> Site Plan drawn to scale <br /> AGENT INFORMATOOI." CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD• SS jiailf well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHO• 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/) ( (Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT Z N ACREAGE / `_ <br /> L i PARCEL O Q O /`Q. O D I 0 O R I I- -- frontage drawn to scale. <br /> NUMBER �Z dYd ' <br /> TOWNSH • S d-ION: <br /> /: 1/41/4: N 0 Drivew mits <br /> 1J a_,..e <br /> ADDRESS: � _ c (state nty,town) <br /> 0 L 0 c) , s ��' ...s 4 6 D Sanita --rmits <br /> CSM: LOT ' SUBDIVISION BLOCK/LOT <br /> 09 / (pub!' , p 'vate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> �C - 1 A�� , zoning Ol filet <br /> x= <br /> . l.T,his project is a new ilding or structure. „e�rmitted Uses.' <br /> ❑This project is an addition/alteration to an existing building or structure. i <br /> SANITARY SERVICE: PERMIT NUMBS ural Address <br /> ❑SEWER I- EPTIC � (ne` my <br /> HEIGHT IN FEET / NUMBER OF STORIES: (Not including basement) l , <br /> / ( Q 161,etla Moat ach <br /> c AREA TO NEAREST SQUARE FOOTh©r ® Bmet7( <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches <br /> BASEMENT: iSTFLOOR: ECOSIOn CJntrOlA'�rml <br /> 3 ,,, TOTAL SQUARE FOOTAGE: (slopes disturbance, <br /> tilling/access) <br /> 2ND FLOOR: 3RD FLOOR: / <br /> 43/7""=7;t!'; <br /> Review c ion Survey <br /> ESTIMATED CONSTRUCTION COST: �� >f and a options r <br /> (Please round to nearest dollar) "'� '--' ♦ --► ♦ ♦ (9 . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yeso ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 44 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? lirles ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes Li 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 ela/No CI Don't know <br /> 7. Is this to correct a violation? ❑Yes I,`�,�lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -o- -+ -+ <br /> 545-112(4108) <br />