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, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 4r/' oh*► 4 e.4-A L f LL ❑Zoning Status; CUP; <br /> OWNER A DRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Li;9j T,,,...v Ii/Ath PRONE� MMCl44,,v,s t�/ s3 s(o.) Variance(# ) <br /> HOME PHONE <br /> 0. - &?6- if. I A : . ' - - O. . ..e Ar ,n/•co... ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO� 4NTR CTOR NAME <br /> H 0 •.15 a etAd.� t�il✓eo // <br /> S,,„:, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /00/ E. ,L/yar r.. /lot/ <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> mnd1s6-", G'l S-37/7 <br /> PHONE PHONE ❑Site Plan approval from <br /> (.(A 5- G2/6,_- Cld 6.) applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 12 Floor plans to scale <br /> S ve4(eul K! - ,Q, ms-0,... ,o.�-.cv4+ <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Q <br /> PARCEL ) g / I / frontage drawn to scale. <br /> NUMBER 6361a)v&-G8-3-7©0/-0 C—p) 3'T ' <br /> TOWNSHIP: SECTION: <br /> /1'wJp/le-I-a 8 1/4: Si,.) 1/41/4: 4/a/ ❑Driveway permits <br /> ADDRESS: I (state,county,town) <br /> y 3y9 7,�,� 161 LOT Ad ❑Sanitary permits <br /> CSM: L T 'SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION . <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 11/46 1•01 "- / 5 'k Soo cif-4- <br /> ❑ Zoning District <br /> . 2<iis 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: ❑ RuralAddress <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodpiain/ <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: 1-1 ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3 C3 0' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► ♦ S QO?� and available options. <br /> (Please round to nearest dollar) ' 1 <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) -► -► -► <br /> 545-112(4/08) <br />