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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Na ti ae.A e ccid M I coal I Sus51'1'1 ck.v..c. ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> U <br /> 76 I H�cide�� �c.�t f p�S Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS / <br /> 6o 798-3) 7'f 608 7l2-317`f 1r1 • a Pelke + ' v)e r <br /> El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> pa ■oh Braille 9 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE 111 Site Plan approval from <br /> 0 g 5 75-Z 00,3 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> C(05S Rams ms IA: %IA: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ;STAFF REVIEW <br /> PROJECT DESCRIPTION: L° ,,, .. <br /> L1 ves-ocle (3arn 3o-P x boct me4- k 01e bare, ❑ Zanin District <br /> P g ° <br /> . ®This project is a new building or structure. ❑ Permitted Used <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: RuralAddr s <br /> ❑SEWER 1:1 SEPTIC <br /> (new/existig) o <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 151+ I ❑ wetlandf Flvodplan/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland 40,00101 <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Erosfnridoltrvi permit <br /> BASEMENT: 1ST FLOOR: <br /> 3 b CI- x w)c,t 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance <br /> 2ND FLOOR: 3RD FLOOR: filling/acp:0ss) <br /> a RevieV■itobatlbbiSurVer <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ e�7 COO <br /> and available options <br /> (Please round to nearest dollar) $ I f <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 El No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? aYes ❑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? DYes ®.No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />