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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE NAME / <br /> i -+,-+./ 4 rfl-TIL t t, /1-e-P r SS ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 5 —L 3 J -__ a l' c .5 I ��/ 6.5/r Deed Restriction; CSM <br /> �`� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> LPDe, 6110 '6bo9 r r-1.-0.e.. 47 4-t r-k of `., ` /'Y._ <br /> ID Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> +-N 04 LLkT-c-i I t 4 ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS � of well/septic <br /> ` <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> (67 oc ) 058, z~r -o applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ 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 /> ❑PARCEL 4/C1 � , ( 1 Li(P frontage drawn to scale. <br /> NUMBER nr �31 a—xi,'•��{,4s p.� � <br /> TOWNSHIP: SECTION: <br /> R {t 1/4: <br /> IhIA: ❑ Driveway permits <br /> ADDRESS (state, county, town) <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> b5'032_ 2-- <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 14-re_ -*1 c c t-nt►-f at ft,c. -- pr .rio.� ...ft' ❑ 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: ❑ Rural Address <br /> FIEWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: I 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 /> BASEMENT. 1ST FLOOR: • ❑ ErosionControl permit <br /> ( Z_ l ti I II_ 2,t 1 K 1(C- Ii-O9' j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> t('' l filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> SD Ct ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ' / p�p .- 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 ONo ['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 glNo <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 ONo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> -C .( <br /> � <br /> - <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -, <br /> 545-112(4/08) <br />