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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 />' GaY PQL✓ Ey ® Zoning Status; CUP; <br /> Y OWNER ADDRESS (Number,Street,City,State Zip) Deed Restriction; CSM <br /> AP /4444' Po L./L.e Y RI 8L e,(a 14104,n 4 1.v-T5 3 5/7 Jariance(# ) <br /> 1 HOME PHONE Cat PHONE E-MAIL ADDRESS <br /> ,tr 977 7779 60? LOc1v7718 [' tePlandrawntoscale <br /> AGENT INFORMATION CONTRACTOR INFORMATION :and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / /' <br /> jj 1site Plan including location <br /> AGENT ADDRESS CONT CTOR ADDRESS /of well/septic <br /> 1 (City,State,Zip) (City,State,Zip) El Setbacks <br /> !' <br /> 1 PHONE PHONE n Site Plan approval from <br /> township. <br /> E-MAILADDRESS E-MAIL ADDRESS ( R!ic ?J <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: 9 CURRENT ZO ING ACREAGE: ID <br /> ❑PARCEL BER (- o ` Yc'9 5 () 0 /4^(2 Co , c? frontage drawn to-scale. <br /> TOWNSHIP: ,, // SECTIO G ' <br /> gi /P�/ d ot/if & 1 1/: N IN 1/4'/a: 0 ❑Drivewaypermits <br /> ADDRESS: (state,'unty,town) <br /> 10494 Rai,101 RI <br /> CSM: LOT SUBDIVISION BLOCK/LOT — ❑ Sanitary0rmits 1 f ($ blicdpnvate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ...il., 'A 74. t� Zoning District <br /> . <br /> This project is a new building or structure. <br /> LiPermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ' ❑ Rural A dress <br /> EWER Ic EPTIC �141 (new/e 'sting) <br /> ff ' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> l J Wetland/F000dplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) Er c. n per, t <br /> BASEMENT: 1ST FLOOR: ❑ O .O.,CQntrol r11I. <br /> 1 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access)/ '\' <br /> L2 if ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: 1 and available options. <br /> (Please round to nearest dollar) –I* --O. -4. -+ -0. ♦ $ / 0 <br /> 1. 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? EYes ao fDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes ❑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 pone) <br /> 6. Is a location survey required? (see reverse) ❑Yes ElI)do QDon't know <br /> I7. Is this to correct a violation? ❑Yes IN No <br /> APPLICATION MUST BE SIGNED 4 <br /> .... 0 , - (Continue on Back) <br /> 545-112(4/08) <br />