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, . ' ,r <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 10441•V? w T 4A-54 l/LS)r) ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 17 Sy Po/2rF1 A,INfl YI1Oo'0 Po Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6•%-$9 S-.25„- Or-g n-e3v/ ❑Site Plan drawn to scale <br /> AGENT INFORMATION j CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZONINg: ACREAGE: ❑Elevation of property <br /> El PARCEL 0190s oR 3 46 I v 0-4-I 3 • to frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> c>1 ,A. ,/,/: 1:1 Driveway permits <br /> U t V° (state,county,town) <br /> ADDRESS: <br /> a-4-C t\ n <br /> �'� M 0 `�`�( Pi ❑Sanitary permits <br /> CSM: 110� LOT SUBDIVISION BLOCK/LOT <br /> / <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C CA,,/ .-c_ ❑ Zoning District <br /> . OThis project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER JEPTIC (new/existing) <br /> HEIGHT IN FEET: c t i NUMBER OF STORIES: (Not induding basement) <br /> _ t2 l ❑ W)etland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 1 TOTAL SQUARE FOOTAGE: ,` (Slope$,disturbance, <br /> fillrg/access) <br /> 2ND FLOOR: 3RD FLOOR: O <br /> , ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: evafl8ble options. <br /> (Please round to nearest dollar) -0. -I. ----- <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Oslo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ Yes al° <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Dslo <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 Dslo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Tplo <br /> APPLICATION MUST BE SIGNED <br /> 845-112(aroe) (Continue on Back) -► -+ -► <br />