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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME A A n ,�) <br /> O n 5 ' " '2/I iS G (A n l 1 et-J1 Li Zoning Status;CUP; <br /> OWNER A�J SS'(yu ber,Stre`t,City, te,zp) s Deed Restriction; CSM <br /> r�vt O Variance(# ) <br /> JH,OM PHO, ) ,CELL PHONE E-MAIL ADDRESS ) I 1 <br /> d�C/o `7`7�725 (�D 8333-�15 C� Sv[/nVJ t ] Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONT_R_L1J (AC it NAME <br /> C`� T)" ❑ 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-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.whus/) <br /> PARENT PARCEL NUMBER: CURRENT NING: ACREAGE: CI r) <br /> of property <br /> ❑ PARCEL ©—)!!\_O Jr. i _3cZ)_9'NUMBER V frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> pp�r)I ro V� c0 5 1/4: 1 E.:es., 1/41/4:_ _ ❑ Driveway permits <br /> ADDRESS: (`'��,�C (state,county,town) <br /> 5C 1 i�v`^' �' ' ❑ Sanitary permits <br /> CSM: LOT 17 g SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION ,-STAFF.REVIEW <br /> PRC,T DE0IPTI N: <br /> h a_t r (�t� (i�-ck Cl Zoning D strict <br /> ❑This project is a new building or structure. C3 Permitted Use? <br /> i2iThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> 14 SEWER 1.:1 SEPTIC <br /> (new/existing) <br /> HEIGHT IN FEET �-, NUMBER OF STORIES: (Not including basement) <br /> 1412./.... ® WetiandRooVain/ <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: itslo�atTttro) �t <br /> c9 // 0/ TOTAL SQUARE FOOTAGE: 0 Pess4istur + , <br /> 2ND FLOOR: 3RD FLOOR: f1l[nglae5s) <br /> // •�t. ❑ Review Location Surve <br /> ESTIMATED CONSTRUCTION COST: Y <br /> (Please round to nearest dollar) •+ —p . •. . •'� 'o. $ �o ) _ and avai bleoptions <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? ❑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) Li Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> )l� <br /> / <br /> APPLICATION MUST BE SIGNED <br /> n (Continue on Back) � <br /> 545-112(4/08) <br />