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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM , 4'0/414 <br /> (4)t..4.— <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number Street,City,State,Zip) Deed Restriction; CSM <br /> 79,0 ei.,t4y 1.4„tr Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4/0 13-1036—y111— ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE MT NAME NAME CONTRACTOR <br /> AGENT OADDRS4� (:),vs r: 1N4• CONTRACTOR ADDRESS ❑Site Pn including location <br /> 7�/ �oSS ,4' of well/septic <br /> (City,State,Zip) �� ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> Goy—f/d-/pr‹) applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Aim;a route;,j,v/4,,.ei6,,sh.«c t ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 1=1 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER RC do 0-7-a// -gs-/--3 /7 f frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> �P s CV* z '/4: IRA: <br /> ADDRESS: permits <br /> ADDRESS: (state, county, town) <br /> 793'0 64 G4,..tr <br /> CSM: LOT /SUBDIVISION BLOBLOCK/LOT ❑Sanitary permits <br /> 8,O!!� 3 , ` (public, private) <br /> PROPOSED PROJECT INFORMATION / STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> A-save-Jr4,, 4,4/s'-1-1.5,..., ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑U Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> (new/existing)[EPTIC g) <br /> FIE <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> i9 Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑-ErosionControl permit <br /> OP 3 Z f (A3o( �j Zf O j, TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ���,�� filling/access) <br /> /iI4 N/4 l ' /1247° ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ 320 oat and available options. <br /> (Please round to nearest dollar) �P i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ❑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 /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -* -♦ <br /> 545-112(4/08) <br />