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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O R AME A /� p ,- <br /> •0 ✓4 __ v` k( CI Zoning Status;CUP; <br /> OW, -ADDRESS (Nu ber,Street•City, •tate,Zip) 'I' ` 3 }'-} Deed Restriction; CSM <br /> b I ca-/-\ 0-yuc GJI Variance(# ) <br /> OME PHONE CELL PHONE - ILAtDRESS <br /> l/0° <br /> V. l 61"-- •//' CI Site Plan drawn to scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includes dimensions 1,,,,,9)AGEN NAME aRCOCAME 1• ❑ Site Plan including location <br /> AGENT ADD CONTRACTOR A DR S of well/septic <br /> ( (City,State,Zip) CI Setbacks <br /> 0..414 ,iIlii9,°I(:) <br /> PH NE PHONE CI Site Plan approval from <br /> 610° %-S3-1-(2\4 applicable township. <br /> E-MAIL DRESS t MAILADDRESS <br /> Loy - <br /> o I C 0284 , ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUM ER: CURR 7 NING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 0111-b -1.41I—' q frontage drawn to scale. <br /> NUMBER U 1 <br /> TOn IP: C.1 SECTION: <br /> 1/4. 1414: ❑ Driveway permits <br /> AD RESS:t � V� i � 3,5......??_. (state,county,town) <br /> 11 ` (: f,\L ❑ Sanitary permits <br /> CSM: LOT 1 S -it) SION <br /> BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT SCRIPTION:(S (J:L/JA bl� 6� ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Ilse? <br /> ;4This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: �,( PERMIT NUMBER: ❑'RuralAddress, "°. <br /> ❑SEWER Jul SEPTIC (new/existing,-ing) <br /> HEIGHT IN FEET: I l " NUMBER OF STORIE 5• (Not including basement) <br /> A Cl Wetlan+d/Fioodplain/ <br /> Shorelant (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ EroSionControj rmit <br /> BASEMENT:4� 1ST FLOOR 1 TOTAL SQUARE FOOTAGE: 4 Mopes,dl li' , <br /> /,/OO_ ♦ fiillin fi CCess) <br /> 2ND FLOOR: 3RD FLOOR: <br /> IIC <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST <br /> -► -► - -I. ►► -1 - - / and available-o ions <br /> (Please round to nearest dollar) Il�J(T.�. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes It o ❑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 kii o <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave bI.nk• none) <br /> 6. Is a location survey required? (see reverse) ❑Yes \No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Wo <br /> 5 3 T APPLICATION MUST BE SIGNED♦ ♦ — <br /> 545-112(4/08) <br /> v (Continue on Back) ► <br /> . <br /> gsol <br />