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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> JEREt -' 1,1c'/c El Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 7�C�9 Fv)(FIf2L 1-12-1 J-UN 6A}I ,c3 Variance(# <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> 6otc- Er3f -falp 4E/LJ e ( 1aIL.cc Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> OW vE(Z ❑Site 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-MAILADDRESS 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 /> ❑PARCEL osHfc9c4 -35y-zlzZ-c R i 2.2 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> SPRimG r It=LIB 1/4; 41/4: ❑ Driveway permits <br /> ADDRESS (state, county, town) <br /> yg. c RoxFI ')RL <br /> Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ <br /> /2_ CMEs2gr t-}ILL (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> p�c K ❑ Zoning District <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER RTEPTIC (new/existing) <br /> HEIGHT IN FEET 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: ❑ ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: l �i <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ -4. -0. $ Z SoC <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ['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? Eres ❑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) Ekes 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 />