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0 67 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA E <br /> ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> fl a US 1-\w' S 1 Mc Far\e.,,A, w ? 5 3s 5 8 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60i- S 3 '=UPC I ,O9-S-7 7-yU SO - I A ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 3u w c' 3L,, late LL-C Sane 2 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7S7( .fr GI- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> 'be ivro—,,-I-/ Go i. 535-32 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 49oZ- f 6- 3341 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> I K p rI.e c t-rn n b . (der S . Lo AA ❑ 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 0/' (0 10 2O0 frontage drawn to scale. <br /> NUMBER �O l V lJ <br /> TOWNSHIP: SECTION: <br /> 1 O '/a: Y4/'/a: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 07074 US Ac 5 l Me,c--TD-r. land (4-17- S 3C-5-g ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIIEV(F ,, <br /> PROJECT DESCRIPTION: <br /> co'-'tier t �ec k w SSA RooM. R.n d a a ru,� d ec,I ❑ Zoning District =3 , <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: ❑ Rural Address 4,5v <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floo lain/a t <br /> � I Shorelarid (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ EroSionControl permit. <br /> BASEMENT: 1ST FLOOR: ° <br /> ZZ 4 S j TOTAL SQUARE FOOTAGE: ,` (slopes,distu bance y' ' <br /> 2ND FLOOR: 3RD FLOOR: fjlling(access) y ', <br /> 22 C7 • S <br /> ❑Review Location Survey , <br /> ESTIMATED CONSTRUCTION COST: �' and available1aptio-i <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ /, c0® A,r . . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes El 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(4/09) <br />