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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App IS <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ,J Arl r 'N Z-1 L— ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City.State,Zip) Deed Restriction; CSM <br /> \O I t--I G) SH A-e-1 I2 D 14-L ∎Aoa W I 5���-1-:)— Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADORE <br /> (6t$ 2)41-G0.3-/ H co-ei� II 0-1-ma■ I o CG 11 ) <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ��U hD CC VI I ) ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑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/) E] Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL C 6 c; 2,43 rS 130L-1 l\ _ I E�( 9 frontage drawn to scale. <br /> NUMBER r� J`' I +� /` / <br /> TOWNSHIP: SECTION: <br /> 1/4: %IA: [' Driveway permits <br /> ADDRESS: (state,county,town) <br /> lC I C S 17 ED *L _ Ho ce (_, 1, ,' `3.7 i LI__,Z n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT ESCRIPTION: <br /> p (G 6_1 rij n de ci< . g i 1,0 I ❑ Zoning District <br /> ❑This project is a new building or structure.. ❑ Permitted Use? <br /> JEThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER 1EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> .-. ❑ 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) <br /> BSEM <br /> AENT: 1ST FLOOR: I ^ <br /> ❑ ErosionControl permit <br /> /4; U 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> /V 0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ Q 2 °� and available options. <br /> (Please round to nearest dollar) $ _ d <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 0 es y; o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? / es 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) ❑Yes No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes 171No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —* -♦ <br /> 545-112(4/08) <br />