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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 /> ` oil l t ell t n ❑ Zoning Status; CUP; <br /> OWNER ADDR S (Numbe.Str t. ity.State,Zip) Deed Restriction: CSM <br /> itt/Lb ����rl nn Variance(# ) <br /> HOME PHONE <br /> El PHONE „.,, , ,,,, E-MAIL ADDRESS <br /> t -71,1 , 134 ❑ 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 (httpJ/accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING. ACREAGE: ❑ Elevation of property <br /> j PARCEL Ct i 1 A/�L ^- Ad q5')J g // A 5..01 frontage drawn to scale. <br /> NUMBER ) �`� �( I K P J <br /> TOWNSHIP: SECTION: ❑ Driveway'/. '/'/a: y permits <br /> MaZOa�aw.'e (state, county,town) <br /> ADDRESS: <br /> /0446 ora 1 RcS ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION ,.STAFF REVIEW <br /> PROJECT DESCRIPTION: .. , <br /> Q Zoning District L <br /> . ❑This project is a new building or structure. a 0- <br /> rmnitted Use? <br /> I@ 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 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2 7‘` Q we€land/Rood'ptatn/ <br /> AREA TO NEAREST SQUARE FOOT: Stu7tec> i� ni <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ca, Eio tCon permit <br /> BASEMENT: 1ST FLOOR: PO <br /> Week 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLO R: 3RD FLOOR: ail 00 �� � <br /> VfleP U,11646-if Location Surve <br /> ESTIMATED CONSTRUCTION COST: d+ <br /> (Please round to nearest dollar) ..+ $ a� 00 arid Vatt bte 4 3tH3FlS <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 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes S 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 ai No ❑Don't know <br /> 7. Is this to correct a violation? CJ Yes 0 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -o -► -o <br /> 545-112(4'28) <br />