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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 /> 4'.n # J 1 (I —SEAS S ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> a i(� -h o,1t Son LA) c�.>?r✓6 6 A) �i , s 3 5�'s Variance(# ) <br /> OME PHONE CELL PHONE E-MAIL A DRESS <br /> `70a)5.--5-1 Oil (og gip• -. /3y n p0 /ov0 ma('/. C0/11 . Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 6.0 tt,`/9�� /2' 6) (-{-j Cd N`i , C-1--L 0 Site Plan including location <br /> AGENT ADDRES CONTRACTOR ADDRESS of well/septic <br /> /0'36 /-I //u-es�- I-J /15,,6 /�i ll cFest 1-1,-) <br /> (City,State,z;p) (City,s etiZip) ❑Setbacks <br /> 0kE dz,nl 1) x35"`7.5 v;CEbo/ J 1,0 .S3S-1 5' <br /> PHONE PHONE ❑Site Plan approval from <br /> (,2Q o)- 1 L 6((AO 6 p a-tl -6 Y vo applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ait'F pr)e d g�"1• �'h, �/Q it,p/)C'i 0 4 0/. C 614 . ❑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 /> ElPARCEL 05/D D O I - C/'/to v /a frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> kC WI A—ThiJi0• '/a: IR : ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 0 CSM: / LOT SUBDIVISION BLOCK/LOT <br /> it/�s public pn'vate) <br /> 5 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /v6 ) 26s it h H AS•Ne e0"1s1-ru.c c+ kJ ❑ Zoning District <br /> . This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER EPTIC /3 - .gy p/el - 00.9.5-3 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ao ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE,FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished ar ,;attached garages and above grade decks o or <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> ,2 1 5 1 ✓ 3 3 5 j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> `C Y- filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> (5-S// <br /> ❑ Review Location Survey <br /> ESTIMATED ED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ `Sr O and available options. <br /> (Please round to nearest dollar) h <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EJYes o DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes o QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es 'lo <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) QYes o DDon't know <br /> 7. Is this to correct a violation? QYes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► <br /> 545-112(4/08) <br />