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40 \tDerad-0 ---- q' 1.- Li, <br /> ' <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME // nn v / y <br /> �?t1d./ '4' DCl4 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (N ber,Street,City,State,Zip) Deed Restriction; CSM <br /> 3J6 j 471j 1 ic/A) PRA/i c Wt 53S'1O Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> i ° "V .'1? .D$ , 0 9-31c8 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> �,tq j )- 20 G ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A RESS 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/) <br /> PARENT PARCEL,NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL Qa/Q$}l-3)3-873a�y #-/ A S�" frontage drawn to scale. <br /> NUMBER 111 <br /> TOWNSHIP: SECTION: <br /> �oo )4v6-- 3 1 1/4: 5V 1/41/4: ul El Driveway permits <br /> s�litJ (state,county,town) <br /> ADDRESS: <br /> 2/( / C,Ty t/w T Sam PA '4ikE ( T S-35-' I) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION r_STAFF RE,. IEW g <br /> PROJECT DESCRIPTION: del;r-� <br /> G-,09�1+y�' Adel� 1/o o II Y2-0 <br /> ❑ Zoning District <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: U.;Rural Address <br /> ❑SEWER SEPTIC (new/existing)rte Z <br /> HEIGHT IN FEET (((/// NUMBER OF STORIES: (Not including basement) <br /> U o 1 D,WetiandlFiootiplaitiC x <br /> // AREA TO NEAREST SQUARE FOOT: Shorelarld (att ,-:::rt) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Erosionconot permit <br /> BASEMENT: 1ST FLOOR: j TOTAL SQUARE FOOTAGE: j slops durba , ' <br /> fillingt.4,4, ss) <br /> 2ND FLOOR: 3RD FLOOR: z_� \ , <br /> _O ❑ Review;Location Survey ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ $ ( Zc am/ and available options <br /> (Please round to nearest dollar) . . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 2I-No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No jI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? .l 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) a Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? 14Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —i• <br /> 545-112(4/05) <br />