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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App 0 <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME w 11 <br /> 1)4uv -1.14,6450 ❑ Zoning District <br /> OWNER ADDRESS (Number,Street,City„State,Zip) g t <br /> _57 4p0/10, �i2 h <br /> PHONE E- AIL ADDRESS ❑ Permitted Use? <br /> 608 873 58,3 <br /> AGENT INFORMATION CONTRACTOR INFORMATION C:3 Zoning Status;CUP. <br /> A T NAME CONTRACTOR NAME S Deed Restriction;CS' <br /> SM <br /> e- FA-(Z,-Oie/r fi)R /� E L Variance(# ) <br /> AGENT ADDRESS CONTRACTOPS ADDRESS <br /> 3818 h C eo4s (le L3 Site Plan drawn to scale <br /> ;City,afire,Zip) (City,State,Zip) v5 —, and includes dimensions <br /> MI4-oISoiL) , (,Wt .537/ <br /> ❑ Site Plan including location <br /> PHONE PHONE <br /> 608 az /73O of well/septic <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Cil-.)/f CI Setbacks <br /> -FARwe8 T frhe,-C•b <br /> PROPERTY/LOCATION INFORMATION (http:0accessdane.co.dano.wi,us/) '" <br /> PARENT UMBER: ZONING: ACREAGE: ❑ Site Plan approval from <br /> ❑ PARNUMBER �T n J CEL Oa/l332R?uQO ��i1 2 /3./ applicable township. <br /> TOWNSHIP e SECTION: <br /> PLe4Sgiv"r-- p lei Dv 1/4: - 1A: <br /> C3 Rural Address <br /> ADDRESS' (new/existing) <br /> 175-1 4P0110 61A <br /> CSM LOT SUBDIVISION BLOCK/LOT ❑ Floor plans to scale <br /> PROPOSED PROJECT INFORMATION ❑ Elevation of property <br /> frontage drawn to scale. <br /> PROJECT DESCRIPTION: g <br /> ❑ Driveway permits <br /> ®This project is a new building or structure. (state,county,town) <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE <br /> LI Sanitary permits <br /> PERMIT NUMBER: <br /> J SEWER 1 I SEPTIC (public,private) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> — _ Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> j, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 672 <br /> _ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ' and available options. <br /> (Please round to nearest dollar) —0. "'. —tr. —i• '♦ $22 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ales ❑No ❑Don't know <br /> - 2. There is 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? ❑Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes No If ctufji k"a`° <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? ❑Yes IA No ❑Don't know <br /> 7. Is this correcting a violation? ❑Yes 14 No <br /> APPLICATION MUST BE SIGNED <br /> a n2 t,roa, - (Continue on Back) —P. -i <br />