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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW.NER N E n n <br /> ( MA-S. a. I `t_n <br /> k) ❑ Zoning Status; CUP; <br /> OWNS ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 19 _ - Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> P <br /> o.1 g.P-c 4 L -1 c� ^^r'e_ e_4_3 s`' , Co'`` ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Li Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CU'RENT ZONIN ACR AGE <br /> El Elevation of property <br /> El PARCEL �(, .J� *401 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: i ( SECT �{. El Driveway permits <br /> 1Lk 1�IC.t \ 1�4: s"" 1,14:SL <br /> ADDRESS: (state,county,town) <br /> `c\a NAY 5‘ � `(-� l �4S$CI ❑ Sanitary permits <br /> CSM: -1 LOT I A SUBDjI.ION BLOCK/_ <br /> P /* �`1 N (public, private) <br /> PROPOSED PROJECT INFORMATION STAFFREVIE1M.0°_ ,:` <br /> PROJECT DSION: <br /> 0:.�4 Er CRIPT �C14, ❑ Zoning District <br /> . <br /> This project is a new building or tructure ❑ 'Permitted Use?_ <br /> VThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ R'ural Address k: <br /> ❑SEWER `4EPTIC (new/existing) ` ; <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) , ' <br /> ❑ Wetiandfloodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (atta5hment} Y <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ExostonCo t, , permit 0 <br /> BASEMENT: 1ST FLOOR: � <br /> 1, TOTAL SQUARE FOOTAGE: ,` (slopes,disturbances <br /> filling/ac ess) ; <br /> 2ND FLOOR: 3RD FLOOR: <br /> d(c. \ ❑ Review Lacatlo Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options <br /> (Please round to nearest dollar) � j <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes `Co ❑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 Silo <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 IP>No ❑Don't know <br /> 7. Is this to correct a violation? ZO ❑Yes 'No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) 0 <br /> t92 (Continue on Back) —► —► <br />