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. ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO'PROVIDE <br /> 0 ER NAME <br /> 1 <br /> OaADDRE a. Numb StC1 ty,State, VI ( Zoning Status; CUP; <br /> '�!� � �, �/ N � Zoning Restriction; CSM <br /> ✓ D 7 (A W , f't ill 10ki(Si 3 2// Variance(# $ ►� - ) <br /> HOME PHONE CELL PHONE --MAIL ADDRESS d <br /> +V/I- ) I 'Q ■ Js" 4 .5.--1 a '. 'Alt ( ,011/0/014//4001, ASite Plan drawn to scale • <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME .-- NAME <br /> irk T 5- .811 /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 /> Al Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL �23 X9,2 O /�_ 5� frontage drawn to scale. <br /> NUMBER Q or ' <br /> TOV ISHIP: SECTION: t , 1� CI Driveway permits <br /> �L a. /<A: (state,county,town) <br /> ADDRESS: <br /> 7 f - 0 14-,(.7e--1/1 A 4 Sanitary perm) 7 r? <br /> CSM: LOT SUBDIVISION BLOCK/L•T (public,private ii, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: _ _ <br /> �_ COO ife J'f-I- -"LAC Mi go-IR ❑ Zoning District <br /> . ❑This project is a new building or structure. 1 O 4 )--)-- k <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMI ER: ❑ Rural Address <br /> ❑SEWER ,SEPTIC � �� (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> 1.1 0 + TOTAL SQUARE FOOTAGE: ,, (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: rs4 filling/access) <br /> -0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: /,../7 o �$ and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,MNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 8I No Li Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? j11 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes JNt No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#v,IL. ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ',Z. o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes R o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ - <br /> 545-112(aroe) <br />