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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVI E <br /> OWNER NAME <br /> ❑Zoning Statu • P; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) f��' .. <br /> 7 �� ��„� , , h ..11-- 5�7;? D d Re ction;CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS r' e(# ) <br /> tOiV- 12 - O O' (o8- Z/7-7\1-63 2s a7,.,--c,zog, cam= <br /> Sit Ian drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME r” / - <br /> �l� `�- Sit Ian including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o ell/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Site Plan royal from <br /> appli a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ❑ <br /> oor s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONIN • ` property <br /> ACREAGE: P P rty <br /> PUMBER p 7c7 7 V60C : i'2. / 11Q0_ Q, 76 frontage drawn to e. <br /> TOWNSHIP: SE�{O0� <br /> P� 7`;e 1°A O( ( 1/,: [ , ,:,..c 6 ❑Drivewa rmits <br /> ADDRESS: (stat ,County,town) <br /> CSM: LOT S :DIVISN C .r ❑Sanitary p- Its <br /> Co K/L (public • Nate) <br /> Y-� i 4 ,'WO • 6" , <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �r7 k�� 12 i L',),,?r,,$ >'�r <br /> n-;,,P 9 0 "' r' I! Z Wing District <br /> . ❑This project is a new building or structure. Permitted Use? <br /> This project is an addition/ eration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural 1•• e <br /> EWER EPTIC Nits t (n- /existing <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /G / / ❑ Wetlan.■�.'•dplain/ <br /> S • :and (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionCo ermit <br /> BASEMENT: 1ST FLOOR: p <br /> /1-y / I] ^c 4, TOTAL SQUARE FOOTAGE: ,, (s p , isturbance, <br /> 2ND FLOOR: 3RD FLOOR: g/access) <br /> N/A.- i\l/r'\ 1 /0.0 S`2 Y(- <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ -4* ♦ —11. -�► $ C 0 a.� _ 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 [3lo ElDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Peso OD on't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes IUIINo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 10 <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) ❑Yes [lo ODon't know <br /> 7. Is this to correct a violation? ❑Yes ✓3lo <br /> C141 W v4 V"'tiK APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -e. -11. -, <br /> s ,A <br />