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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME C <br /> L A L- ��', - c V`'61‘ ❑ Zoning Status; CUP; <br /> OWNER ADDRESS ( ber,Street,City,State,Zip) Deed Restriction; CSM <br /> 3,S , \3' 0 - to u� 7 , Variance(# ) <br /> HOM 'HONE g'LL PHO E i E-MAIL ADD-S•S y_ <br /> ,♦, (33S-14 ((eo$ 22O•-91 . - • 4b a•. _' -ke-c` c-.' b Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTUR INFORMATION and includes dimensions <br /> CONTRACTOR NAME <br /> 1I;1 V ❑ Site Plan including location <br /> AGENT.DDRESS CON R' TOR ADDRESS of well/septic <br /> (City,State Zip) (City,St- e,Zip) 0 Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> N I- E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: frontage drawn to scale. <br /> NUMBER I 0-0. 3 .. <br /> ❑ PARCEL e d — c ` A <br /> TOWNSHIP: SECTION: <br /> 17jWk_ Pf 462-,— x <br /> 1/4: 1/41/4: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 1, 1. r <br /> ' _ •t ❑ Sanitary permits <br /> CSM: MEM. SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION ;STAFF REVI <br /> PROJE DES RIPTION: <br /> ❑ Zoning District <br /> his 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: PERMIT NUMBER: 0 Rural Address -- <br /> (new/existg) <br /> ❑SEWER SEPTIC in <br /> HEIGHT IN FEET: NUMBER OF STO'IES: (Not including basement) <br /> UMWetland/PIoacplelt>/ <br /> Shorelar d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑'ECOSionCOntrO' ern11tk <br /> BASEMENT 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: +, (Slopes,, ,., -,banes', s <br /> filling/access) `` <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey r <br /> ESTIMATED CONSTRUCTION COST -0. ♦ . -0. -0. $ and available options r- <br /> (Please round to nearest dollar) , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No Won'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 Oil 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 *o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes likNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />