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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME i L L <br /> �E P F q'� kit It MK 5ON Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> > C 5p i N G Rose c!K Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> G*fjq, -3/ a t ✓4'1 45 1.( -"5 , q r r Bite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 121te Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) V Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ErFloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:!/accessdane.co.dane.wi.us/) �Ievation of r <br /> PARENT PARCEL NUMBER: ) rCURRENT ZONING: ACREAGE: property <br /> ❑ <br /> NUMBER c)CO b 7- I\ - 3d( y k 4+-,j 2 410 1 M` 3 •7 -) frontage drawn to scale. , i <br /> TOWNSHIP: n SECTION: r J U <br /> 5 7 RI/tic 4911(-6 Al V ihy.. N[ Driveway permits ��/ /'`� <br /> ADDRESS: (state,county own U <br /> `/ 66 5f i't G Ao5C CIK N <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary p <br /> Q S O / \ (publi •rivate 0, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: LA/ <br /> Zoning D b I T-i 0/1 LA Zoning District <br /> ['This project is a new building or structure. ti Permitted Use? <br /> (EIThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ' •••- . <br /> EWER 7SEPTIC (n- /existin• <br /> HEIGHT IN FEET: u / NUMBER OF STORIES: (Not including basement) <br /> / Vhetland/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 /> ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 3 3 C? S3 O 4, TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: O <br /> stiifilling/access) <br /> Review Location Survey X <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ $ �13 D 0 Q <br /> / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes /61Plo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ao ❑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? laes DISlo <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 M'lo ❑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(4108) <br />