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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NPS����� n_ :: /1 <br /> /I �'�(CJ//l, �t(/l� �/ <br /> El Zoning Status; CUP; <br /> OWNER ADDRESS (N/u�mber, eet, itySatte,Z ) Deed Restriction; CSM <br /> �` l� Q( IY Variance(# ) <br /> H( HONE CELL PHO E E-��ILADDRESS <br /> � � i I I `4/�� N6 AI'vii I J&.' ) ' Site❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRAId 1 G/ <br /> NAME ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,StnIZI ip) p ❑ Setbacks <br /> 4,eitil.el PHONE PHONE ❑ Site Plan approval from <br /> po , - syl) applicable township. <br /> E-MAILADD SS E-MAIL A DR S <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CU ENT ZONING: ACREA E <br /> ❑PARCELQ,^ �,p������_Q�n�rj _� frontage drawn to scale. <br /> NUMBER 0�o o O I `u ' ! <br /> TOWNSHIP: ECTION: <br /> 16\W\ ' . )(161 1'J-1 t I '/a: %1/4: ❑ Driveway permits <br /> ADDRESS: ,S-109 (state, county, town) <br /> wn) <br /> DIM CP 4O ! W f o ) Q i 3 O <br /> CSM Lf SUBDIVISION B El Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> fv. N Po: .' ❑ Zoning,District <br /> x=t <br /> . ❑This project is a new building or structure. ❑ Permitted Uses <br /> Ifihis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMB ER: LI Rural2Address <br /> DEVVER 'PEPTIC (new/existing) , <br /> HEIGHT IN FEET��� 11KK66 11�1��� a NUMBER OF STORIES: (Not including basement) <br /> 0.-Wetland/F000dplain/; <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FL0 ❑ EroslonControi permit-- <br /> I�" /*1� I qD5 ,, TOTAL SQUARE FOOTAGE: ,' (slopes sdisturbance, <br /> l(l Q{� ( ` `''/N filling/access)' <br /> 2ND FLOOR: 3RD FLO 1 lea a ( .; ,i <br /> ❑ Review location Survey <br /> ESTIMATED CONSTRUCTION COST: ��} d� and available options. <br /> (Please round to nearest dollar) ♦ "'∎ ♦ ♦ -► --► $ .3.Ev V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes b o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? `EYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Lives "lo <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 grg"No []Don't know <br /> 7. Is this to correct a violation? Lives ►, o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —0 —0 —► <br /> 545-112(4/08) <br />