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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 /> L/T $1. Sc4 oning Status;CUP; <br /> OWNER ADDRESS umber,St City state,zip) eed Restriction; CSM <br /> a,C52 - A./V. <br /> R IAND 1nZ' 5355? Variance(# ) <br /> ,40M PHONE,, CELL PHONE El AIL\ Sao 435T 9 35f95 S p atesCO <br /> p7 Pte/ FA Site Plan drawn to scale A t <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions/ - ��1 <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) 'JaSetbacks <br /> PHONE PHONE 4313ite Plan approval from ii P <br /> applicable township. / it_ <br /> E-MAILADDRESS E-MAIL ADDRESS 6 <br /> Floor plans to scale 12., <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) eil Elevation of property 4''V <br /> PARENT P �jEL N MB CURRENT ING: / ACREAG <br /> Li PARCEL /�� ��g ) 5271 �/ �� �� - rontage drawn to scal <br /> NUMBER Y ` //: <br /> TOWNSHIP: n SECT: j_ / G� h�� Driveway rr - //4 B 1/4: w '/41/4: (state,county <br /> ADDRESS: c Z �7 _ <br /> f� [Sanitary permits Aiil <br /> CSM: LOT BDIVISION f BLOCK/LOT (public,private) /1 <br /> PROPOSED PROJECT INFORMATION STAFF REVS F I l <br /> PROJECT DESC ION: <br /> 4- S (4.4 r S , ` S Zoning District' , _ / 2- <br /> ti This project is a new building or structure. Øermitted Use`s <br /> ❑This project is an addition/alteration to an existing building or structure. =- �°-: <br /> SANITARY SERVI PERMIT NUMBER: <br /> - Rural •+ ��'lei <br /> SEWER ❑SEPTIC (neW xisti <br /> HEIGHT IN FE ) NUMBER OF STORIES: (Not including basement) <br /> / Wetland/Floodplainl <br /> Shoreland (attar i tertt <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: i ST FLOOR: �Eros10C1Controt Permit <br /> IF TOTAL SQUARE FOOTAGE: 4, ,.(slopes disturbance, i <br /> 2ND FLOOR: 3RD FLOOR: 111 - 4�/a` oess)-Z. 1 <br /> fillin <br /> Review Location ely <br /> ESTIMATED CONSTRUCTION COST: / /� /1 Q and available options <br /> (Please round to nearest dollar) ♦ ♦ --► ♦ ♦ ♦ / C� V 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 13 No Dbon'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 />