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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> QWNER NAM <br /> \\ 1)I e i 1'i '7 /4e ❑Zoning Status;CUP; <br /> OWNER ADDRESS N er,Str et,City,State,zip �1 Deed Restriction;CSM <br /> 6/O oC[CL <br /> ��� 7 Variance(# ) <br /> HOME PHONE CELL PHON E-MAIL DD SS <br /> /f <br /> G°Y 3 -- ‘36 ° C,� ,4, @ t hSC. ecat& ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NA L <br /> S-'G hie, 9-'1-udZ t fS'/4 6 ❑Site Plan including location <br /> AGENT ADDRESS CONTRADR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) '/ ;35-72_ 11 Setbacks <br /> /y�ahl' /10h12 cca <br /> PHONE PHONE / ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOW H SECTION: <br /> e1-+ k--/— '/4: %IA: ❑Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> q)66/ /1ou0t°1� X IIL i. D�L <br /> CSM: LOT d SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT SCRIPT)ON: <br /> C/C ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER cEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <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: ❑ ErosionControl permit <br /> ,l TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 'L/L6-- .0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ D and available options. <br /> (Please round to nearest dollar) $37,2 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes 111Vo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? J Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? rglYYes ❑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 ❑No [Don't know <br /> 7. Is this to correct a violation? ❑Yes to <br /> --� <br /> 545-112 i4/08i <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> . 8 n <br /> P <br />