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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVID <br /> OWNER NAME �T <br /> 30tin anACe e( U)A " Zoning Status; CUP; <br /> OWNER ADDRESS (Number,S�ee_t,-C^ity,State,Zip) 1 eed Restriction; CSM <br /> 115 96 ( i'1CC[n wcxy <br /> Co C 1% <br /> e 6.2),/c wr-5S,? Variance(# ) <br /> HOME PHONE CELL PHONE t-MAIL ADD ESS) <br /> ,0 g-q01/-07_ (b f'V/-0 7,5 , c r6roiA^ <br /> e iv fzem."let /I'ii Site Plan drawn to scale <br /> AGENT INFORMATION JONTRACTOR INFORMATION -nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> 30/15//°/C-17 <br /> PHONE PHONE Site Plan approval from/��6 <br /> pplicable township.A1 /�_ <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> /r /(� <br /> X Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> D PARCEL frontage drawn to scale. <br /> NUMBER /jI,141- <br /> 1%:TOWNSHIP: SECTION: 141/4: Driveway permi <br /> ADDRESS: (state,count , ow <br /> Sanitary p- a•'ts /f' <br /> CSM: LOT SUBDIVISION BLOCK/LOT �(publi • <br /> PROPOSED PROJECT INFORMATION (. iI <br /> „..PROJECT DES�RlPTIOt�l:O i U /fr <br /> CSM: . District � !',. <br /> . OThis project F a new buildin• •r structure. Permitted Use? <br /> ❑This project is a -•• ion/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 14:Rural ° <br /> ❑SEWER SEPTIC (new/ 1s • 1 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> WetlandtFESIOplatn/ 3 <br /> ShorelaldA attachment <br /> AREA TO NEAREST SQUARE FOOT: i C <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: / /'� ErosiOnCn>ntrvGsermit� air <br /> // / / 4, TOTAL SQUARE FOOTAGE: ,l, (slopes,d turb; P ' <br /> 111(((//J Lf filling/access}„ F <br /> 2ND FLOOR: 3RD FLOOR: ! / /7 <br /> t/4,', C 1,Revfet Laea:tlor4 Survey ; <br /> ESTIMATED CONSTRUCTION COST: $ / n /) /'► and available options <br /> (Please round to nearest dollar) -"∎ '♦ -► ♦ ♦ --► / 0 Gt (,� t g , . M <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? XJ.YeS ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Ilo ❑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) El Yes allo ❑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 />