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,c <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAMt pec k <br /> OWNER ADDRESS (Number,Street,City,State, ❑Zoning Status;CUP; <br /> 75 Deed Restriction;CSM <br /> 3 5 r r�s,er �Q ce Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6178 (n0g-512-373g S-lev&.vt • ' 5`/� <br /> " 64 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> E Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> E Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> ARENT I\/I PARCEL PARCEL,O7/�NUMBER: �.A ��CURR- `I�JG: �.aI ACREAGE: •3 3 '� frontage drawn to scale. <br /> OW NUMBER `/ ' V G1 dtG�CIN _f •r 1W <br /> TOWNSHIP: SECTION: of !v <br /> B ham%A &We 35 1/4: me 1/41/4: N W ❑Driveway permits <br /> ADDRESS: J (state,county,town) <br /> 83is Lt r ?lace., JHe. arlanei, M.)Ii 53555 <br /> CSM: LOT SUBDIVISION yl. BLOCK/LOT ❑Sanitary permits <br /> 13 `LH�1I_•L�1 aka (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: D e(.34 <br /> — +' a <br /> A�+�Y l b 20 ❑ Zoning District <br /> . ❑This project is a new building or structure. <br /> Use? <br /> / ❑ Permitted Use <br /> This project is an addition/alteration to an existing building or structure. <br /> p <br /> SANITARY SERVICE: ,fit, PERMIT NUMBER: ❑ Rural Address <br /> EWER V �EPTIC (19w/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> © Wetland/F000dplain/ <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: 1--, <br /> ErosionControl permit <br /> +, TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 80 6'r' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ..+ -* �o 0 and available options. <br /> (Please round to nearest dollar) I -D <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes .121No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Oyes D.,0 0Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? IYes ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes al <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) Elves Jlo ❑Don't know <br /> 7. Is this to correct a violation? [Yes ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ —► <br /> 545-112(4/08) <br />