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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> ` w ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi ) Deed Restriction; CSM <br /> 3 9 S9 (-)i I v1 o v r . G��hcr.) w V "5-3 S 7 5 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADD SS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -SD k kl 6 &C . l4 o rn.t. Sp-e-x----P-3-b-A- ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS lieu; / . H of well/septic <br /> w3o /O v,� e_ �v30/o- S .3 N "„, <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> PHONE PHONE (-) I:] Plan approval from <br /> (p p V-3 c —6'13 0� S o,,.,--k- _ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURREN ZO ING. ACREAGE: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER c� -o Id -��� ?8 1 g <br /> TOWNSHIP: SECTION: <br /> '/a: '/h: ❑ Driveway permits <br /> ADDRESS: <br /> DJ 11 h ' (state, county,town) <br /> 3 S? (..,o,` ∎m or - {�v' - „`' �w's 5 3- ?3 <br /> � ❑Sanitary permits <br /> CSM. LOT �j SU:•MSION BLOCK/LOT <br /> }✓{ �� s � (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 0 S c .,-., Jt W on--(...1,‘ , ❑ Zoning District <br /> . This project is a new building or structure. <br /> ❑ Permitted Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> r)EWER 'PEPTIC ex, (new/existing) <br /> HEIGHT IN FEET. NUMBER OF STORIES: (Not including basement) <br /> 2- /� 'i� /)- / STOle P S ❑ 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) I—, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> fl 0, (/�d0-r ii on ,, TOTAL SQUARE FO• •GE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filing/access) <br /> X1-1 cats k ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ ♦ ♦ ♦ 56� , and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eves ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Lives ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves ❑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 ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -♦ -* <br /> 545-112(4/08) <br />