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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> -Ke 1C\ AK olQ'a' ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) S'-?S 27 Deed Restriction; CSM <br /> '}.7Y y p „t PheAS(INV Ksik \ CO tfC (/v)C 'mot Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 77o—Y3i ' ❑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 CONTRAC1VOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE 1 ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAILADbRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION..(http://accessdane.co.dane.wi.us/) [' Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 0/g 0711 _OSY 5�3 -J R..../ <br /> NUMBER U,y8 S frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Co P-Qyc Cro.ie .1/4: <br /> 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state, county, town) <br /> )...7`l`r P/t s a1 CkAr ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> `t X `l C� 4�e APD/riO,► Zoning District <br /> This project is a new building or structure. �,,� <br /> • ❑ P j 9 Ltd Permitted`Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ` •..[- <br /> DE1NER [EPTIC (new 'xisting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ry / etland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: horeland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: roslonControt permit <br /> C�� j TOTAL SQUARE FOOTAGE: l $lopes,, Disturbance, <br /> .7 / c-. <br /> Unglaccessy <br /> 2ND FLOOR: 3RD FLOOR: <br /> 16 eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ l5 00 0 'arid 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? [Yes ENO ❑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? ❑Yes Ell No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Iles ®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) [Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> '. \' 13. a6 APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -i -♦ <br /> 545-112(4/08) <br />