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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> R ° >1 j,I 05 et—r ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) / Deed Restriction; CSM <br /> I y a 3 Lee Rd Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (44'iCP.-7Y02 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> USite 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-MAILADDRESS <br /> ❑ Floor plans to scale V <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: Q/�� CURRENT ZONING: ACREAGE::) C, fron ratan to scale. <br /> ❑NUMBER Oq K-001'0��1/V-0 ?vk-� /, <br /> TOWNS�/HIP' /� SECTIO • <br /> O L )n D-f Dq n e 1/4: '/a'/a: ❑ Driveway permits <br /> ADDRESS: U (state, county, town) <br /> -4- ` Z� L r--V■ El Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> ■ <br /> PROPOSED PROJECT INFORMATION ' STAFF REVIEW <br /> PROJECT DESCRIPTION: S4- It- c) ci,R S 11 ed ❑ Zoning District <br /> . <br /> This project is a new building or itructure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER / EPTIC `� new/exlstln <br /> ( g) <br /> HEIGHT IN FEET: I it 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 /> BASEMENT: 1ST FLOOR: ❑ ErosionControi permit <br /> 3 S DO j TOTAL SQUARE FOOTAGE: l (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: r 3 ,7DO <br /> / 0 Review location Survey <br /> .4 �� <br /> ESTIMATED CONSTRUCTION COST: $ y D 000 -- - -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 MNo ❑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'? EYes LINo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? nYes 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) Dies �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 />