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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> A � -) • <br /> 1 ,--�/ <br /> OWNER AD ESS bStreet, ate,Zi JS/ L✓� zoning Status; CUP; <br /> ��� Cu, r- �� Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHON 5S 7 E-MAIL ADDRESS <br /> '2 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGEN�jNAmk // CONTRACTOR NAME <br /> /� c/[-er A t L_ Ac.,k€ /' 6 v I!eal.4 1N C [Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 33/ E..4)1 c 57 <br /> (City,State,Zip) (City,State,Zip) j"Setbacks <br /> A)Gc v 4, ktQsz..., (U ) <br /> PHONE PHONE. Site Plan approval from <br /> e ,50 - G ` 0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> lElloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 2/Elevation of ro ert <br /> TL <br /> —' PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ' NUMBER .`0 7--17/-fo eo-O A- B 1-L-/S frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 5 pr,I 1h: ,/4,/4: Driveway permits <br /> ADDRESS: (state, county,town) <br /> CSM: /»• 4 / LOT �� SUBDIVISION BLOCK/LOT —L_J "anita •_ ••�� <br /> 1 __ -- <br /> iO 4 c .-4,� (publil, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: AC2/.43- Ifr.1-IL / <br /> Zoning District <br /> This project is a new building or structure. Ly Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ R I Address <br /> SEP <br /> F1SEWER TIC new/ xisting) <br /> HEIGHT IN IN ET: NUMBER OF STORIES: (Not including basement) <br /> 4 Wetland/F000dplain/• oreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST R <br /> ErosionControl permit <br /> 117 ,, TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2Ngp j filling/access) <br /> p�� / •� Review Location Survey <br /> ESTIMATED CONSTRUCTION C ST: QQ�� ,�eems� C!� /+^�� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ "♦ $ 'T'g 7 Cv 7 p <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 g Bon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes to <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 EvNo ❑Don't know <br /> 7. Is this to correct a violation? El Yes ON <br /> 1 <br /> 4 qc6I APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />