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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER M ,--�� <br /> 01 E ft-R C ST R <br /> tC ❑ Zoning Status;CUP; <br /> OWNER ADDR SS (Number,Street,City,State,Zip) ,+ <br /> 1-111 B/a R R4 ea ` t? G � i i -�5:n Deed Restriction;CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Variance(# ) <br /> $ir1 - 112-5 I), -1,10f3 , <br /> Kl NW I{ MI i% V42"NsilCh• - ' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Li 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 PARCE NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> LI PARCEL O iP/o 11 i -1 IL .4 low-5 R - 1 :7 8.5 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ., <br /> 01 ( j 1/4: !Q uJ "/4%/4: Ki W f ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> M451 51 136�-)Z g 6 ❑ Sanitary permits <br /> CSM: LOT 4.0 ' SUBDIVISION BLOCK/LOT <br /> r (public,private) <br /> • ' ' • • • ' ' • • • ' " = 4 ■ STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Rive vX%Sl1 J&I 6 x10 pc+t4't A IOdx29 s' ( ❑ oning District <br /> C:._„';, po( Lln <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or str - - . <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER Wi SEPTIC (new/existing) <br /> HEIGHT IN FEET: r NUMBER OF STORIE : 'ot including basement) C3 ti <br /> Weand/FIOOdplain/ <br /> .. t —1 '/2 wctl is /I -Mk �— <br /> AREA TO NEAREST SQUARE F••T: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached gara. s and above grade decks or porches) <br /> BASEMENT: J3:41” OOK: ,---. ErosionControl permit <br /> +, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: al-to <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ $ / Ar, and available options. <br /> ♦ <br /> (Please round to nearest dollar) 3bv"e 017 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes id No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®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? til 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) ❑Yes ,.No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes kli No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► ■ —I. <br /> 545-112(4/08) <br />