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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER( �E, p <br /> I / 4 FrLACte/N LUVvj ❑Zoning Status;CUP; <br /> OWNER a RESS (Number, City,State,Zip) Deed Restriction;CSM <br /> t/)fleel ilt\0un1 k - C(✓ 7v✓t P✓�t.(rIt LJ l `aM3�dl() Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 'a As / •I alf&O' 0 O+^') A14417.1 e uw ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATIO11 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 El 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/) ❑Elevation of property <br /> ❑PARENT PARCEL NUMBER: CURREI�TING: ACRE frontage drawn to scale. <br /> NPARCEL UMBER dh if•-T�'(,-0)65-9 /.-[ �i� V r' <br /> TOWNSHIP: SECTION: <br /> �}y U ,/: ,/4,/. ❑Driveway permits <br /> ADDRES , (state,county,town) <br /> (petCui 4 K�i54f- t,aa 'wPVwrY`iZ, L/j 5-351 a ❑Sanitary permits <br /> CSM: },�,,, LOT SUBDIVISION l' BLOCK/LOT <br /> ��� VP SSG" �„l,_ i '4 (public,private) <br /> PROPOSED PROJECT INFORMATION ')F STAFF REVIEW <br /> PROJECT DESCRIPTION: A, 1,'_ <br /> G ❑ 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 /> EWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> lti — ly / 1 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionControl permit va <br /> 4 TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> WO ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ -4. ♦ ♦ -0. and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dees slo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o Eon't know <br /> 3. Have you talked with the township about your project and are they in agreement? }Yes LJVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes C Vo <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? Dees [i io <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ ■ -► <br />