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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O j NERINAM <br /> ;hi ri���beIv a ` l pl2a Cry Zonin Status CUP; <br /> R S5�(Number,Street,City,State,LA) ❑ g <br /> lad l /(24 . v7` i'// IC( ri S f u ¢oN 1,0.E c�3 c g� Deed Restriction; CSM <br /> / l Variance(# ) <br /> HOME PHONE CEL HONE E-MAIL AtDDRESS <br /> .7' 046-7 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> AGENT ADDRESS • Cje,try 8u,'/ai t) 1U/"/ ❑Site Plan including location <br /> ON f RACT ADDRESS / of well/septic <br /> (City,State,Zip) (City,State,Zip)O 1 9301 go/ j//1 /V4/' wi 5 31-;g3 ❑Setbacks <br /> PHONE "PHON ❑Site Plan approval from <br /> ( 4p- ) 72. -Q S applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PAUMBER RCEL OS71 JO! S'300 (, T4 — 7, 61'15 frontage drawn to scale. <br /> N <br /> TOWNSHIP: SECTION: <br /> 6 u A)1(1/4.‘r 4 1A: 1/a,/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 1�6/ //eRSa Vt i` 7/ ❑Sanitary permits <br /> CSM: d LOT SUBDIVISION BLOCK/LOT <br /> 6� 4 0 , (public, private) <br /> PROPOSED PROJECT INFORMATION REVIEW <br /> STAFF PROJECT DESWIPTION: / <br /> ()Old r� / )(KaCG(lilleV , bi/e-S1C/� ❑ Zoning District <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> EWER RIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> o2a r '' ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 02,2 Q j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: C, filling/access) <br /> 0,2a6 Li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �( ��� and available options. <br /> (Please round to nearest dollar) <br /> 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? ❑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# 8°// ) (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 ❑No <br /> CI D— t /d APPLICATION MUST BE SIGNED <br /> 545- (4/08) (Continue on Back) -► -► -► <br />