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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER E _ <br /> SS L_ �-�-;-Q�r� ❑ Zoning Status; CUP; <br /> OWNER ADDRESS ( umber,Street,City,State,Zip) Deed Restriction; CSM <br /> 3S -S 1� 1,3 S 0 tt- v,s-S— S3S�7 r Variance(# ) <br /> OME PHONE CELL P ( E-MAI ADDRESS <br /> $3S-- 1 9 9 8 Z20—`3 III- ❑ 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-MAILADDRESS 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: ACREAGE: frontage drawn to scale. <br /> ID NUMBER 0 3-7O-OS3 /p Soo 3 <br /> TOWNSHIP: SECTION: 1 1 1 ❑ Driveway permits <br /> �-o & ,� 1��� /a: /a/a: (state,county,town) <br /> ADDRESS: <br /> 4/13St Slit k, 139i I p,,- A_ LA.JE 6357,.- ❑ Sanitary permits <br /> CSM: LOT a SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION ''STAFF REVIEW ; ;.' <br /> PROJECT DESkTION: <br /> ��nn--QQ__ ❑ Zoning District ;* <br /> ❑This 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: ' Ruraf address <br /> (new/exiSting) t <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) - <br /> Q-,Wetland/Floodplain/ t <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> Eraslonr;ontroC�erntit <br /> BASEMENT: 1ST FLOOR: ' . <br /> +, TOTAL SQUARE FOOTAGE: , (siopes,"diaturbandelr <br /> filling/access '` <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location`Survey . ," <br /> ESTIMATED CONSTRUCTION COST: $ and avatfabteoptions <br /> (Please round to nearest dollar) ♦ ♦ -i ♦ ♦ -�► <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 ❑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 ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0. -► -* <br /> 545-112(4/08) <br />