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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 /> lAYLog /'YlApE Nom�5 L L- ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3( if 4-S,v i DA! 1.9 R. OiL 'ohv4// to z .5'3s?3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> SO • 0 3 /a di I I Si ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> KoeR l wiri E,2.5 /rey5 reur4- Rk;ire.a S ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3/ N q-SN Toy L9 le„. ----,(City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> 1/540 ru A w L ,r3 513 —› <br /> PHONE ' PHONE ❑ Site Plan approval from <br /> 6.01c S-2$. (o qa o .--- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> a ,N B e •S• , Cz- —'"" ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> ENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> NUMBER 050$^ /4.1c1 - /t0/-4 2-3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> MOw TA I V 1/4: N1✓ '/a'/a: Nit` ❑ Driveway permits <br /> T (state,county,town) <br /> ADDRESS: <br /> 7 3$ lip Nit r go ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIE1lf <br /> PROJECT DESCRIPTION: <br /> L0Ee K^ /et $1 1-2-- ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted_Use?., <br /> a$This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address 1z <br /> ❑SEWER ❑SEPTIC (flew/exisating) � � , <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) "' ,' <br /> ❑ WetlandlFloodpl4iit! <br /> AREA TO NEAREST SQUARE FOOT: Shorelar d (ote-filent <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionControl permttf <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturb lncer <br /> 2ND FLOOR: 1$NZ 3RD FLOOR: filling/access) <br /> /q / / 1/5/ft ❑'Review Locationn Survey ,:: <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► ♦ ♦ D •� and available options <br /> (Please round to nearest dollar) 710 ,,, <br /> f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes Ja3 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? CI Yes XI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? UYes 0 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 XI No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► ■ —► <br /> 545-112(4/08) <br />