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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 /> /o "/ / S%t` — ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 3V7`7 liA y ke/. G✓A fit' A,,,,i kiz s3s`56 <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ✓J <br /> Pei,//u's MU? 4 y #6A.56,d 1� /D��/e S ,zc . ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> //0 ,3A,£<c 5-'/- Sv/tf / /10 6n 4/.c S7(i 5-v)fc d <br /> (City,State,Zip) (City,State,Zip) D Setbacks <br /> (,{/,4 u.v,r k4 4 /cl 7. S-3 5-- .? &Ad ciw•v k_L. G./17 S S—C) <br /> PHONE PHONE 1 D Site Plan approval from <br /> Y-y - Y7? C Fy q'- ->3 G applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> /ust.v ,,,/a4Its ( T'S 'A/6 r-- 1 6,,5,,i /3v,'if its , TjS•,ust ❑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 /��ia o�"/4--‘o -9 _� frontage drawn to scale. <br /> NUMBER 0/y <br /> TOWNSHIP: SECTION: <br /> suit ±ki .? ' : '4-N '/a'/a: C. ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> I c/ 7 7 &A y¢c e/• ai4 <br /> D Sanitary permits <br /> CSM: LOT S SUBDIVISION /� BLOCK/LOT (public,private) <br /> coY!'Naon ? ///5 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5C 4.4‘, /470,2 ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> 121This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: LI Rural Address <br /> EWER rEPTIC (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: ❑ <br /> ErosionControl permit <br /> 3 3 - 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> O filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 0.0 33 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ QQ�� and available options. <br /> (Please round to nearest dollar) .p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Elo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EINo ❑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 'lo <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) Dyes o ❑Don't know <br /> 7. Is this to correct a violation? [Yes o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(a,oe) (Continue on Back) —► —► <br />