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ZONING PERMIT APPLICATION wVvw.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ITNAME VI 5/t ( ❑Zoning Status;CUP; <br /> OWNER ADDRESS Nu be Street,City,State,Zip) Deed Restriction;CSM <br /> H�! PHONE �OCELL PHONE a I � 7LEApDR�SS / �� Variance(# ) <br /> 88 Y-8S Yd ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME C NTRA•TOR NAM _ <br /> (a.L1r (��;0 -I-KC, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD+ESS L / of well/septic <br /> '3 4 k J f eio <br /> (City,State,Zip) (City tei Zip) q ❑Setbacks <br /> Ste L.,/, W, 5 ,5o/ <br /> PHONE PHONE ❑Site Plan approval from <br /> 6408 - 3 YS- gd a applicable township. <br /> E-MAIL ADDRESS E-MA AD)RES rr <br /> Sit 11' c h oo/e_ /J5 AI, e viA ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CU N �°NING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL _'I frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION ❑Driveway permits <br /> 11,oIA 4 v.:SE ,A1A: <br /> ADDRESS: I (state,county,town) <br /> )0/ E( o`i 1,04 1 ❑Sanitary permits <br /> CSM: LOT ' 1 SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D CRIPTI N:r Q <br /> De c ova' '1'o 1/‘ CI 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: ^"'���ttt PERMIT NUMBER: CI Rural Address <br /> EWER (/// OEPTIC (new/existing) <br /> HEIGHT IN FEET: ((( NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached gar$es and above grade decks or porches) I—, ErosionControl permit <br /> BASEMENT: 1ST FLOOR:t�.-7 I <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: \�n filling/access) <br /> �' l ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ ♦ ♦ Q 0 ° and available options. <br /> (Please round to nearest dollar) $ �j�0 <br /> I <br /> 1. The property is within 300 feet of a stream or 1000,feet from a pond or lake? Efres "lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your projet and are they in agreement? Yes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 111No <br /> 5. Is this project associated with a rezone/CUP/variane(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) 4 Ekes ❑No ❑Don't know <br /> 7. Is this to correct a violation? [Yes alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) <br />