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Wt <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS AME / / <br /> Le it rw Li C G. ,t.c'S n c-'SS ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi p) <br /> 11,9? S y L o� f i/,v,J /ni- <br /> z.,ic, ad/ /0 j S 5 Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> g_3 '/WO z--S y/C /I)0/1e ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ 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/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> / ❑NPARCEL BER o�k/D U ?i. 60/2 --2, frontage drawn to scale. <br /> UM <br /> TOWNSHIP: SECTION: <br /> 1/a: '/a'/a: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION .",STAFF REVIEW <br /> PROJECT DESCRIPTIOI)l: <br /> t�pL a/c c K bG'a /SS ❑ 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 /> pqEWER SEPTIC (neW/existing) ; <br /> HEIGHT)N FEET: NUMBER OF STORIES: (Not including basement) <br /> 16 f1 �� C/_ j ❑ Wetland/Flood plain/, <br /> iAREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 15T FL o ❑ ErosionC;ontrof permit ,' . <br /> 3 .5 j, TOTAL SQUARE FOOTAGE: 1, (slopes,disturbance) <br /> J " filling/access)' <br /> 2ND FLOOR: 3RD FLOOR: 2 „ '' e <br /> ❑ Review Loeatlori <br /> Survey <br /> ESTIMATED CONSTRUCTION COST: '- and available options. <br /> ♦ --► - --► --► -- <br /> (Please round to nearest dollar) <br /> $/ 7.37 <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? fYes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? KlYes ❑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) Elves ❑No ❑Don't know <br /> 7. Is this to correct a violation? Dyes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —0 <br /> 545-112(4/08) <br />