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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 /> 6'**WA-- ZwI .1001 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State ip) Deed Restriction; CSM <br /> 5 Z.. c_c)CP.j` i Variance(# ) <br /> HOME PHONE / CELL PHONE E-MAIL ADDRESS <br /> ii - - LI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ 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.wiusl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: toC-1D ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 5J Z _292—/21 3 2 A_Z(i) 021, frontage drawn to scale. <br /> NUMBER l <br /> TOWNSHIP: SECTIO <br /> Aheld N 2 1/a: ,� J w 1 1 /E ❑ Driveway permits <br /> 1. �v /a/a: <br /> ADDRESS: <br /> 5 � � /� � de � (state,county,town) <br /> !lam <br /> of/ADDRESS: <br /> y o <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ,",,1 - <br /> �■ Zoning"District <br /> This project is a new building or structure. <br /> ❑ Permitted Uses C G <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> 44 - <br /> SANITARY SERV E: PERMIT NUMBER: Rural A 6 6 SS <br /> SEWER ❑SEPTIC <br /> HEIGHT IN F'ET NUMBER OF STORIES: (Not including basement) <br /> Z a Wetland Foodplain/ <br /> 'Jr,imisoULAL,r--lii sJ re, 8I entj <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or -• ® <br /> BASEMENT: 1ST FLOOR: 35lLIn � )~IIlt w <br /> +, TOTAL SQUARE FOOTA $13eSr <br /> .r <br /> - ,ate.i� <br /> 2ND FLOOR: 3RD FLOOR: X73'' <br /> ESTIMATED CONSTRUCTION COST: _ ❑ Review D..oca� urvey <br /> (Please round to nearest dollar) '♦ "♦ "♦ "� "♦ '� 1 d t and avaeptionS z. <br /> r <br /> r5 Z'b' eT3 <br /> 1. The property is within(300 feet of a stream or 1000 feet-from <br /> Si <br /> a pond or lake? ❑Yes ®•No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ■ Y( ❑No 0 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) ❑Yes IA No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes A No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ —► <br /> 545-112(4/08) <br />