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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 /> J Q n-, €s e �4 Zoning Status; CUP;A-—(I <br /> C)( <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> )WSCre.e,n) t?b 5roulCt-G Iv INS $- 58'9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> bOa-‘9?FS-00,3/ Site Plan drawn to scale f <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimension <br /> AGENT NAME CONTRACTOR NAME /� <br /> Ird Site Plan including locati lu/r <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) „El Setbacks 6 340 /0/1/4"0 <br /> PHONE PHONE Site Plan approval from , 1 <br /> applicable township. N f_ <br /> E-MAILADDRESS E-MAILADDRESS <br /> Floor plans to scale �/ /� <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.us/) Elevation of property X <br /> PARENT PARCEL NUMBER: /� CURRENT ZONING ACREAG <br /> El NUMBER /P O ^392-�” -2^C A —/E, �Lr S Z frontage drawn to scale. <br /> TOWNSHIP: SEC lO // �j� <br /> 1/4: /I '/a'/a: /U r /zypriveway perm <br /> �1 " (state, coun ,to <br /> ADDRESS: <br /> Sanity . <br /> CSM: LOT SUBDIVISION BLOCK/LOT (publi iiiieP <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT_DES�RI�PTION: /3 / _ /O L , � /� i s. �( f- C) 4 e,k.`,,<_ oning District ,ii--:,4 <br /> ❑This project is a iding or structure. 5'''`"1 Permitted Use? pF �� <br /> This project is an dition/ Iteration to an existing building or structure. A.,:;4-e_ <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Ad•=ss f p <br /> EPTIC (ne �� Vim' <br /> rEWER 1 <br /> HEIGHT IN FEET: `�/ NUMBER OF STORIES: (Not including basement) Wetland/Floodplain/ / <br /> S AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) F; ErosionControlgermit > <br /> BASEMENT: 1ST FLOOR: <br /> 5-10 j, TOTAL SQUARE FOOTAGE: j (SIOPES,disturbance, / <br /> 2ND FLOOR: 3RD FLOOR: filling/access) - , <br /> ��0 a Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ 2- co, 06 and available options. ill( <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eyes ENo ElDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Eves fNo ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Elves ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [—Yes ENo <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) Eves ENo ['Don't know <br /> 7. Is this to correct a violation? Dies ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue�� Continue on Back) -► -1 <br /> 545-112(4/05) <br /> 8 <br />