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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App # <br /> , <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER NAME <br /> NAME L rJ l <br /> C g/ (e Z Wing Status; CUP; <br /> OWNER ADDRESS (N tuber,Street,City,State,Zip) r G \- eed Restriction; CSM <br /> /1 r ,Ui /GATT G©l/{e� R(� _ U i S -'`�J ariance(# ) <br /> HOME P NE` b CELL PHONE E-MAIL ADDRESS <br /> • La 5�� ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAM <br /> ,SC1y ivJreUC77o J//I.--t. tli to Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> f�a 5v c — D -( <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> 1 ; c✓r s 357 3 ❑ ..'- <br /> PHONE PHONE ite Plan royal from <br /> L,o e - `d rs 3 20 p li e township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> (1).f C%/ox '•ws re✓c ,✓ Co, oor plans to scale <br /> PROPERTY/LOCATION INFORMATION .(http://accessdane.co.dane.wi.us/), <br /> PARENT PARCEL N BER: CURRE TZO ZONING: ACREAGE: Elevation of property <br /> 1=11 <br /> PARCEL (: ((�� C� I� C q, 1 frontage drawn to scale. <br /> NUMBER ©`j l) 1 / ]V <br /> TOWNSHIP: SECTI ,� <br /> ��G Y1Q� ' '/4'/a: S� ❑ Drivewayfmlts 4_ )0 _t_f_ /4" (state;aunty, town) <br /> ADDRESS: (S —{. ,.. <br /> CSM: LOT SUBDIVISION BLOCK/LOT El Sanitary-permits <br /> �� (,• blic, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJ rDF�SCRl lO _ 0 �r A ilrelare w oning District <br /> . ILI his project is a new buildinrror structure. ❑ Permitted U. ? <br /> ❑This project is an addition/Iteration to an existing building or structure, <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural dress <br /> FIEVVER , EPTIC /\s (new/e lstin <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not includi bas ent) <br /> ❑ Wetland/Flo ain/ <br /> Shore' (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages anti above grade decks or porches) (--1 ErosionCClntr0l It <br /> BASEMENT: 1ST FLOOR: �r- .a all <br /> �II���/L/� 4 TOTAL SQUARE FOOTAGE: 4, (slopes,d1st ante, <br /> 2ND FLOOR' 3RD FLOOR: /ill..✓// filling/ac s) '. <br /> � 0 ❑ Revle Location Sury ,IN <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --P '— '— ,� and available options. ; u <br /> (Please round to nearest dollar) $ c2t 000 <br /> % <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes 4alo ElDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes grNo EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves alo <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 EINo ❑Don't know <br /> 7. Is this to correct a violation? Elves EjNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -♦ <br /> 545-112(4/08) <br />