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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMEWeb-App <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> • <br /> OWNER ADDRESS gZoning Status;CUP; Q(Number,Street,City.State,Zp) <br /> CI-1-"k Deed Restriction;CSM ) / <br /> • PHONE PHONE Variance(# ) <br /> . at p <br /> �- Site Plan drawn to scale A <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions , (7 <br /> Site Plan including location C <br /> ADDRESS AGENT • of well/septic <br /> AGENT NAME CONTRACTOR NAME bis Lin(City.State,Zip) (C' ,State,Zip). , .305M Setbacks .305M <br /> PHONE • Site Plan approval from <br /> applicable township. fl/ • <br /> 2 Floor plans to scale <br /> PROPERTY/LOCATION INFORMAATION (http://accessdane.co.dane.wi.us/) :',..' <br /> DPARENT PARCEL - ����CURRENT-ZONING: •-it ACREAGE: .1, L-Elevation of property rr <br /> NU BER " lQ� _ ; ei.%r, !`1 r, r frontage drawn to sca ,� <br /> TOWNSHIP: �`-- S SEC I A� <br /> i a "D 1 ) %4: // 6 %4'/4: Driveway permit <br /> ADDRESS: <br /> (state,county own <br /> 02 0 1A-Xtn � J Lk.)> JC' <br /> J\ 5 1 Sanitary its <br /> �7 <br /> CSM: LOT S BDMSION r<00,4 BLOCK/LOT <br /> 1 . C d (public, rivate)� <br /> PROPOSED PROJECT INFORMATION <br /> JE.C[T[ ° jCRIPTION: STAFF REVIEW <br /> V •"O C,j�'1 a L --i- tJ t>•,,i of e - , e c-1(--- Zoning District ;r'J 1 / <br /> OThis project is a new building or structure. permitted Use? <br /> 125"his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 4 Rural Ad•_:ss <br /> FISEWER rEPTIC (new!- <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> :0 m 1 EV Wetl.p-4 Ioodplainl ,f <br /> `_'� AREA TO NEAREST SQUARE FOOT: �'� .I(attachment) �+ <br /> (Outside dimensions including unfinished area,attached garages nd above grade decks or porches) ,- <br /> BASEMENT: 1ST FLOOR: ,. ; ) � /- ErosionControl permit <br /> �` 4, SQUARE FOOTAGE: (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: N.N to U�' filling/access) <br /> x884')-`2 <br /> . ► -eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: i ♦ ♦ —► ♦ and available options. <br /> (Please round to nearest dollar) $ o/ 0, U Do . bo <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes . io QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes F i o []Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? . Yes I o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EJYes ao <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) Q''es , to Epon't know <br /> 7. Is this to correct a violation? [Wes ao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -. -I• <br /> 545.112(4508) <br />