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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 /> 3'bH■ otZ 54yE, Info LL A E GEfZ ❑Zoning Status;CUP; <br /> WNERADDRESS Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2 9 dI Lofnc,Q {Zook of C4rrnbr'i of,Q 1.vS 6-3 5-2 3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4,68-14Z3 -3(p - ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 134 'WAS/46 u r-el ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS / of well/septic <br /> // /V A.,,,e '1 c., ,, S4-e-e e T �h..to it �1 <br /> City,State,Zip) (City,State,Zip) ' ❑Setbacks <br /> c4O h ) t.is 5-303‘ <br /> PHONE PHONE ❑Site Plan approval from <br /> (pig- 215- - 00) 0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ItiA,,2r t 1,..5-S 1.Is(-a- ,r,w,,4-t1 b�;7d.►}j CC✓h ❑ 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 /> 4( UMBER O IZ36 38 coo 1 f}- / (Ek� 2 0 _ frontage drawn to scale. <br /> TOWNSHIP: (T4g9Al SECTIO N: l `C4 4rot IZ (2 E� , 3b�lv_lz 1/4 /W k1/414. sW ❑ Drivewaypermits <br /> �'ES (state,county,town) <br /> ADDRESS: <br /> Z9° b[a LL.,..e ru . ❑Sanitary permits <br /> CSM: 2 LOT SUBDIVISION BLOCK/LOT <br /> ^-- (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO 1!<CT ESCRIPTION: [ <br /> ( rte r iN S71tsr<ti e) 36 )(G® LI Zoning District <br /> . NThis project is a new building or structure. LI Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMITNU B R: 13 Rural Address <br /> r)EWER Y PEPTIC 1J (new/existing) <br /> HEIGHT IN FEET: j 3 NUMBER STORIES: (Not including basement) <br /> LI Wetland/Floodplain/ <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: ❑ <br /> ErosionControl permit <br /> l-l'6 +, TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: WC) <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) '♦ ♦ ♦ ♦ ♦ ♦ $ 5-0 COO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes g]No ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IRNo EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes INo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes WNo <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) eyes �No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -♦ <br /> 545-112(4/08) <br />