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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 /> jq""6 ‘/.- earn ❑ Zoning Status;CUP; <br /> OW R ADDRESS (Number,Street,Ci , tate,Zip) <br /> /�� �T- Deed Restriction; CSM <br /> HOME PHONE av r i�CELL PHONE 7-/ E-MAIL ADDRESS <br /> Variance(# ) <br /> 60,f_ p3 L/-2/476 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .E/VDI9$5 4;73. ./vc ii LL ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACT R ADDRESS of well/septic <br /> iv 3a' / /i/d`v /)il <br /> (City,State,Zip) (City,State, ip) ❑ Setbacks <br /> ..4,is 4J j 3`372 <br /> PHONE PHONE ❑ Site Plan approval from <br /> O L/94/— 37VVo applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> e "Ht 4‘5 67 AJ !Skive• ne ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wii.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER RC OW/ -333-e76/-o /Imo/le.'d � , S/`�' frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ,S(/.7 0/t! rde— 33 1A: 51✓ 1/a14: /I/k/ ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 4/691 e& y',7, )T <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT ESC IPTION: <br /> //t/710) ❑ Zoning District <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 /> ❑SEWER ❑SEPTIC (flew/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ' <br /> 1 ( ❑ Wetland/Flao+dpGlain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ l Erosionuontr <br /> permit <br /> BASEMENT: 1ST FLOOR <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: W qRD FJ CzL�U QR: <br /> 76,8- <br /> S1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ l and available options. <br /> (Please round to nearest dollar) /O/Cr)'D• ; <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes e-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? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 2-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 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -0 -► <br /> 545-112(4/08) <br />