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A ►6,3 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM '1 <br /> ad,Ai-)1 t6t tU./ C ,-.0.. ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, p) Deed Restriction; CSM <br /> (, pi;Q � l�puu( �} 531 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> o •2 2 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -\/b ; 6 ___, j ❑ Site Plan including location <br /> AGENT D RESS CONTRACT ADDRE S of well/septic <br /> (� .t3 4CrtItt, CA' <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> VAA)tt(V2 °E 5- 5q1 <br /> PHONE ■ PHONE ❑ Site Plan approval from <br /> c '2- ig .5 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZQNING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 111 (\ frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP:i�( SECTION: J <br /> V 11k 3 1%. (3 1/41/4: lj Driveway permits <br /> ADDRESS: (state,county,town)tb <br /> b(O-�b 1 4Y ' ` <br /> c� L ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> A 210 PROPOSED PROJECT INFORMATION STAB REVIElAt l <br /> PROD E i1ESCRIPTION: 11f <br /> VESS <br /> ❑ 2oning IStrtet <br /> . ❑This project is a new building or structure. U_,Permitted Use74. <i <br /> 2iThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ •Rural Address <br /> SEWER ❑SEPTIC ;;;:,(6074:01#06§1-414U41104 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) a <br /> O Wetland/Ffoodpl in/ <br /> AREA TO NEAREST SQUARE FOOT: ShOreland �attcl'tmen} <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) aas <br /> E'l oStoncQntrf ermtt <br /> BASEMENT 1ST FLOOR: 7 <br /> 1'C�� C a� , TOTAL SQUARE FOOTAGE: ,l 1(slope disturbance, <br /> )J J� pv filli g/accce s) } <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2 q0 <br /> ❑ Review IOCat:ott Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �� rJ D� and avatlab(eopti sns <br /> (Please round to nearest dollar) $ I _n,d_ .�, ble 11:. ': <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes lai 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? ,o Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes £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 EI No ❑Don't know <br /> 7. Is this to correct a violation? DYes 6 No <br /> S BE SIGNED <br /> + <br /> (Continue on APPLICATION BacMUk)T -* — <br /> 545-112(4/08) <br />