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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE AME//ll,,,, evi/V�'11 a/ a laig `- ❑Zoning Status; CUP; <br /> OWNEADDRESS (Num r Street State Zip)( p> , Deed Restriction; CSM <br /> HOME PHONE/9 5 &O L PH T � E-IOI AIL ADDR`ADDRESS <br /> 6i/ `'W, 4-s`r 3 Variance(# ) <br /> ,A , `' , • / 60$-V341$/G • ❑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-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) E] Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ <br /> PARCEL DQb "' I1 2.40O2_' Q T Z frontage drawn to scale. <br /> TOWNSHIP SECTION: <br /> '/a: '/4'/4: ❑ Driveway permits <br /> G� Q� _—lfUl (state, county, town) <br /> 4q <br /> ADDRESS: eisiv ']d gvicethdcw, s3-5-ff3 k <br /> CSM: LO SUBDIVISI BLOCK/LOT ❑Sanitary permits <br /> �0 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 4 GI-r5 ,e_ 75 >I- 4/0 ❑ zoning,district <br /> . ►.This project is a new building or structure. ID Permitted Use? <br /> r,, his project is an addition/alteration to an existing building or structure. ;;; . <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FTEINER PEPTIC (new/exlsting) <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not including basement) <br /> /3 0s ❑ Wetland/Floodplain/, <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) 3_ <br /> BASEMENT: tST FLOOR: r-1 trosiom;ontrai permit <br /> /goo 4, TOTAL SQUARE FOOTAGE: j (slopes)disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) Y <br /> ❑ Review Locatioi Survey <br /> ESTIMATED CONSTRUCTION COST: $ 3� 00 and available options, <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ -�► <br /> 8 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes Tjk-o ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? Des LMP4i ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'es [i <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des IUXo <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 it ['Don't know <br /> 7. Is this to correct a violation? ['Yes []N <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -it -* -+ <br /> 545-112(4/08) <br />