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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM 1. <br /> t..*- ' ❑Zoning Status; CUP; <br /> OWNER ADD Number S eet City, Zi <br /> // ( ty, Deed Restriction; CSM <br /> Z /741.�"d`C //y ��s�'ST �/"- Variance(# ) <br /> HOME PHONE CELL PHON MAIL ADDRESS <br /> 0t.33Z'8G't/ ❑ 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 CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑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 /> 1=1 <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG ' <br /> NI PMCBEELR Og1D-031-(p1t 2 p.- D i2- 1 0.4- frontage drawn to scale. <br /> TOWNS SECTION: <br /> ttAA-e '/a: '/a'/a: ❑ Driveway permits <br /> ADDRESS: <br /> O K (state, county, town) <br /> � °�55 �oINY�T� t� ( ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ackyavi (.A $ i1S1M( dick eadfri ❑ Zoning District <br /> . ❑This oject is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ RUral Address <br /> FIEWER 0EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I <br /> ❑ Wetland/FlOOdplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControi permit <br /> S3"b j TOTAL SQUARE FOOTAGE: j (slopes`disturbance, <br /> T filling/access] <br /> 2ND FLOOR: 3RD FLOOR: S w <br /> Li,Review Location Su rveY <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) "∎ "'$ -+ --0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [`INo ❑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 ]No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies 5NNo <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) lYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Dies laio <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) - -► -9 <br /> 545-112(4/08) <br />