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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 /> 4 T a re. I ( C A— ❑ Zoning Status;CUP; <br /> OWN R ADDRESS (Number,Street,City,State,Zip) 5-3531 Deed Restriction;CSM <br /> 53 c a ov y 7 R.oa� T T l/1'1 r5bcc/I W2 Variance(# ) <br /> HOME PHONE CELL P ONE E-MAIL ADDRESS <br /> bQf. 35-8 S-73 0 k-2,5-4 873 144r`ckxNackl a 6 O 4/'// C o J Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5'e / F" ❑ 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 /> Q Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZO ING: ACREAGE: 0 Elevation of property <br /> ❑ PARCEL Q$11/.45-(1626—6 /9� (Y� S frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> -Cu ri Pr c i r le ,Rq*(( ' : Pik T ' h:Cows I fP Driveway permits <br /> ADDRESS: (state,county,town) <br /> 5'3Ao2 6s.vpry kac ck T T ❑ Sanitary permits <br /> CSM: COT SUBDIVISION I BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> $ufi` ;iii <br /> PROJECT DESCRIPTION: F eq.. - <br /> i' o!`4 n/S 7,w t� <br /> 4�t 1 r 6 ok 1O .6 •0. p .C� 'f (6�l /O rG i zoning District <br /> . ❑This project is a new building or structure. 0 Permitted Use? <br /> 'This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 RumiAddress <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> / 7` . 0 / J 0 Wetiand/Fbodpiainl <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ rOStonC it <br /> BASEMENT: 1ST FLOOR: y� <br /> D c2 1 4, TOTAL SQUARE FOOTAGE: 4, (slopes.,es, ist nce, <br /> 2ND FLOOR: 3RD FLOOR: ,1 �n ` ) <br /> 26 4tL11: 9.7 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) <br /> /. , 0oa <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 allo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? l3Yes ❑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 .15No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes .INo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► <br />