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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS NAME <br /> -e- -e_fY1LAS ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ` Deed Restriction;CSM <br /> HOME PHONE , CEL�E � LO 1 �� Variance(# ) <br /> (j.-212=J I- 7 L1 (set► --)-C- 1.DA12 tilLtsc1t Loo. ae+Y1 ❑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-MAIL ADDRESS 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 NING ACREAGE: <br /> ❑NUMBER Oi w/0 JO—031-23. ..,0 '1 . 3 Q frontage drawn to scale. <br /> TOWNSHIP: SECTIO : <br /> Tt�ll1 rl 0( ,exif lL4._ 1/a: '/4%: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 10304 ?el i . -Q- Ce S W t 5c-33 Z- ❑Sanitary permits <br /> CSM: LO a. SUBDIVISION BLOCK/LOT (public,private) <br /> IWS <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> rj <br /> it$ de ck ❑ Zoning District <br /> . <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER KEPTIC (new/existing) <br /> HEIGHT IN FE 77 NUMBER OF STORIES: (Not including basement) <br /> 2.' ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 4 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ -► $ 225 va <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes 4lo ]Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres ❑No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes EiNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ❑No 'Bar, - k-r-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 alo ['Don't know <br /> 7. Is this to correct a violation? ®Yes alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -e -e -e <br /> 545-112(4/08) <br />