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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> �/ / CUSTOMER TO PROVIDE <br /> owNr lGI'1 -4 C)�/-r I0 fit Wit n d <br /> b� 0 Zoning Status; CUP; <br /> OWNERADDRE S (Numbier,Street,ci , ate,Zip) Deed Restricts n; CSM <br /> 30b f4l�tSS kdk Mew) 6bhe'ys r S3�y Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 66 AL -y�l�� EfSite Plan drawn to scale <br /> AGENT INFORMATIOP CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME " CONTRACTOR NAME <br /> r0 ,a\`` G 51k^e ... t.ti � �q rn S Site Plan including location <br /> AGENT ADDR � ^ 1513 CON RACTO ADDRESS �Q �p of well/septic <br /> (City,State,Zip) PQA` - ~'(City,State, ip) ❑Setbacks <br /> PHONE �.`+`",�y�� PHONE/,�9C� 1� // ite Plan approval from <br /> e.V_O s vv U [ -6— 7 f b 5 applicable township. <br /> E-MAIL ADDRESS .-`� E-MAIL ADDRESS <br /> dFloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> 11NUMBER OSO 362 NUMBER: _ CUR�}ENTZONING: ACREAC r,, frontage drawn to scale. <br /> PARCEL �JJ�. 11 (i// <br /> TOWNSHIP: SECTIJ_ <br /> �r; n, �p S 3!o f 7 '/4: /1W '/4'/4: ,IV ❑Driveway permits <br /> A DRESS: !� (state, county, town) <br /> let, 1'£e-z -cs R"� AA it) 6IAPIr'f 4`°-1� 5.35-7$1 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6,-,,,r) `)&SW- G 0 5-‘khd5 ❑ Zoning District <br /> Is oject is a new uilding or structure. <br /> Li Permitted Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> DEWER rEPTIC (new/existing) <br /> HEIGHT IN FE,)E - NUMBER OF STORIES: (Not including basement) <br /> / ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> BASEMENT: <br /> L �0 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: /SD <br /> ESTIMATED CONSTRUCTION COST: ❑ Review LocatlOn Survey <br /> (Please round to nearest dollar) ♦ ♦ '� ♦ ♦ ♦ S 3 �Q and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes o JDon't know <br /> 2. Is there a wetland or floodplain on or near the property? EVYs o DIDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? I__ ess alo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if n ne) <br /> 6. Is a location survey required? (see reverse) Des o Don't know <br /> 7. Is this to correct a violation? Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br />