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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1 I <br /> Seas No 1 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number, <br /> Street,City,State,Zip) Deed Restriction; CSM <br /> HOME rower D ( y, S�U1 n �SJ 3�p Variance(# <br /> ) <br /> P ONE E ADDRESS <br /> '. •--/ao-4oa3 essho4h - ho+ iai(.eon-, ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -Tess 1-104-1/1(Owwev> E N6e- ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE — ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 1=1 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER Btu� 1 -/7/-&837- R-I ,63 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> if aSa.n 4- Sp n nq S 17 Y.: �/a�4: 12 Driveway permits <br /> ADDRESS: V (state,county, town) <br /> a573 &VL4)n 'Dee/ 12t ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> c;17 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6a.raae w/ lean(enclosed' D Zoning District <br /> . ©This project is a new building or structure. © Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEINER [EPTIC (new/e)isting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> l(D' peak !l' walls I(''8'� al. / ❑ Wetland/Floodplain/ <br /> ' i r 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: <br /> ❑ ErosionControl permit <br /> 38 X 1 TOTAL SQUARE FOOTAGE: (slopes,distu nce, <br /> 38 J� fllingi ss) <br /> 2ND FLOOR: 3RD FLOOR: <br /> /900 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available Options. <br /> (Please round to nearest dollar) $ 95`! 000 <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? ❑Yes NNo ['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 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 ao EDon't know <br /> 7. Is this to correct a violation? ❑Yes la No <br /> 4) <br /> ( ) ' APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -► -► <br /> 545-112(4/08) <br />