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• ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O NER NAME X r�- <br /> k4 etT c 1 ed I�l 1"ft. ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 l& 1 sif 11 fk!( - # • -- Variance(# ) <br /> HOME�PHONE CELL PHONE E-MAIL ADDRESS <br /> e l l 1 , -03 ; — t; - , 30 _Co2 t? .-- (I •c, El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <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) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ 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 /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ttoAM 1'4€ to R.d vE 1/4: 141/a: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> , 3 2 <br /> PROPOSED PROJECT INFORMATION F ,STAFF REVIEW <br /> PRO T ESCRIPTION: 1,11-001AJG <br /> l t�O A) To UPP te- Got,�,ttin otece - efut<J6 Sm as TO c4 ❑ Zaning District'. <br /> . ❑This project is a new building or structure. ❑'.Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC Nr'+ (new/existing) <br /> HEIGHT IN FEET: NUMBER STORIES: (Not including basement) ' <br /> ❑ Uvetiandi ob:c plain/ <br /> Shoreland (attachmer t) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ <br /> EoseosnC Q (ro p m <br /> tt <br /> BASEMENT: 1ST FL0 R: `( lop ,dstrbi <br /> / ace� <br /> �, TOTAL SQUARE FOOTAGE: $, s u 'fillin /ccesst , <br /> 2ND FLOOR: �r 3RD FLOOR: <br /> j& 1� 3 y ❑.Review LocationTSurvey. ` <br /> ESTIMATED CONSTRUCTION COST: / artd avatlable options <br /> (Please round to nearest dollar) ♦ --► -► ♦ ♦ --► $ < 0���V ,. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a< ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Y,--�Ces ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? LII" ❑No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank iif one) <br /> 6. Is a location survey required? (see reverse) ❑Yes IJNo ❑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 />