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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU•TOMER TO PROVIDE <br /> OWNER.UAME <br /> tJ C E "3 E " C(Z V ,oning Status; CUP; <br /> OWNER ADDRES (Number,Street,City,State,Zip) geed Restriction; CSM <br /> 7 ( C-Ty V U Variance(# ) <br /> HOME PHONE CELL PHONE d E-MAIL ADDRESS let N 7R • <br /> Go9 g'�P P z 81 0 ,o 9 - 'j 3 QE�N,i�k q � F p-o 'rt rc R <br /> w, - “., , C.o V Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION anlincludes dimensions <br /> AGENT NAME CONTRACTOR NAME 1 <br /> V Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Site PI approval from <br /> a plic ble townsh' . <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> lour s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) Elevation of property <br /> PARENT PARCEL NUMB // C RENT ONING: ACREAGE: P P y <br /> ❑NUMBER 6‘../('' L. ���� � , S/ frontage draw scale. <br /> TOWNSHIP: SECTI N: <br /> tS )Z( S To L- '/a: SE_ /4'/,( 5-r <br /> — ❑Dri te,county,( y' ) <br /> —W.o g 3 Lz 7 I-1 I t,`-t (,,, A-/ V V ❑Sanita rmits <br /> CSM: LOT SUBDIVISION BLOCK/LOT U private) <br /> PROPOSED PROJECT INFORMATION .TAFF REVIEW <br /> P <br /> fil.T cv-t-.O 614R„c}4 ■ Z I ning District <br /> . iThis project is a new building or structure. C "ermitted se? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ;Z. <br /> EWEREPTIC (new/HEIGHT IN FEET: NUMBER OF STORIES: (Not inclu ing basement) <br /> IZ r't�a,� ❑ WetlanAREA TO NEAREST SQUARE FOOT: Shorelttach ) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ EroslonContr permit <br /> C) .Z 8 j TOTAL SQUARE FOOTAGE: + (slopes,di rbance, <br /> 2ND FLOOR: 3RD FLOOR: q fllling/a SS) <br /> / Z ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ —P. -► —/P —P. and available options. <br /> (Please round to nearest dollar) $ 1 3 QO O <br /> , <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? [Yes ®No . <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Y ®No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le a blank if none <br /> 6. Is a location survey required? (see reverse) es ❑No $ '.on't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> n 1.---- APPLICATION MUST BE SIGNED <br /> l UJ (Continue on Back) <br /> 545-112(4/08) <br /> --4 f <br />