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i !k `-�` lG�" Ay '"S P S P`PLEMENI' to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAA,,E <br /> Lr01'414 4yrfs• ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, i ) Deed Restriction; CSM <br /> 13 3 3 S-4rat-W vY� CIL, /i'l.3/4 t K//f'G • Variance(# ) <br /> HOMEPl-ONE CELL PHONE E-MAIL ADDRESS /j r <br /> ✓ 3y _ ' ' i • 5 elf- /TO r - ce. ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (Ci'y,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE TI 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/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL ,q �� frontage drawn to scale. <br /> NUMBER 2`708'35-/-q 770-g f ar'65 <br /> TOWNSHIP: SECTION: <br /> T <br /> (� Sp riNs /C n ,/4: ,/4,/4: El Driveway permits <br /> (state, county,town) <br /> ADDRESS: <br /> 6 C 5-6' 6'rr eh l)n'et r Rd. 7Oton erf- Spe,t1-P11. <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Li Zoning District <br /> . ❑ This project is a new building or structure. ❑ Permitted Use? <br /> IE-This project is an addition/alteration to an existing building or structure. ll <br /> SANITARY SERVICE: PERMIT NUMBER: J Rural Address <br /> flSEWER ✓EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 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) n E,.vvionCo^trOI 'ermit <br /> BASEMENT: I1SI FLOOR: ry 1 <br /> y TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: '/ <br /> . l �� ❑ Review Location Survey <br /> at ESTIMATED CONSTRUCTION COST. $ 2 DD0a,2 and available options. <br /> (Please round to nearest dollar) <br /> l <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes l❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? n Yes ►VNo n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes [v]/.o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes [v 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 dNo n Don't know <br /> 7. Is this to correct a violation? lErYes EN o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ♦ -4 <br /> sas„z taioe> A 1 0-2 V 2 <br />