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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AMI <br /> _a f'� a5 �-e, ZL <br /> OWFIE RESS (Number, reef,City,State,Zip) , El Zoning Status; CUP; <br /> /) ,per Deed Restriction; CSM <br /> ` 5 •T:57-c; ��� -c,J Variance(# ) <br /> HOME PHONE ` ELL PHON E-MAIL ADDRE <br /> 67 ' 7-3 ,' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT AME / L2.� CO TRACTOR NAME <br /> c,/-C.,"2. (I eV ) �G Jt ,,f /U1 /d4A ❑ Site Plan including location <br /> AG NT ADDRESS CONTRACTOR.A.RD DRESS 74_,_ of well/septic <br /> (City,State,Zip) (Ci ,State, ip))/4,���; // ❑ Setbacks <br /> PHONE (/,/'` L/v <br /> PHONE ❑ Site Plan approval from <br /> 'S6'-t<4<-S'0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> A <br /> NUMBER C Cie°Z71-5-.3;1-7-J4 P-- ( 3 cyi gas -4�/f frontage drawn to scale. <br /> TOW Hi 1_ SECTION: 16'"'� <br /> T Sz.,400 1/4: 1/41/4. ❑ Driveway permits <br /> ADDRESl��e�/ L� a � (state, county,town) <br /> C$M� r �/ LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (� i �7 572-Ate 5 r- (public, private) <br /> PROPOSED PROJECT INFORMATION , I STAFF REVIEW <br /> PROJECT DESCRI TION: <br /> /04)-1-104-c ❑ Zoning District <br /> his project is a new building or structure. <br /> LI Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> (SEWER EPTIC (newleXISting) <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not including basement) <br /> 30 ❑ Wetland/Floodplain! <br /> AREA TO NEAREST SQUARE FOOT: <br /> - Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑, ErosionControl permit <br /> rl 3 vq 94 7 0 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> /� filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> S © Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ..+ --► $ .,' 7 cJ ?7 and 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 [✓]N<o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Jo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? .... [I es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? b ❑Yes 21Clo <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ?itt 0 ) (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 Gan <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />