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, ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS M E le5" N r12 / 7i' 5 'n ❑ Zoning Status; CUP; <br /> OWNERA9D'L • (Num r, eet,City, ate,Zip) <br /> i Deed Restriction; CSM <br /> 9d f I o ®/?e d,^e9a0 l �3� Variance(# ) <br /> HOM PHONE CEL HONE�1 E- AILADDRE <br /> ' V/ 45 ,`/' 22."0/,'/,,._ ����A�� ❑ Site Pl�drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE AT NAME CONT TOR ME <br /> 1J ea J gile,Ili i/J C/ Q 1�° `�� ,, / ,, s lIC�f 17 ❑ Site Plan including location <br /> AGENT AbgRESS CONTRACTOR ADD €s of well/septic <br /> P <br /> L/. ./, �Z'���©`1 z° 4 <br /> (City,State,Zip) (Ci State,Zip) ❑ Setbacks <br /> ) 'Vet, '7 *"�3.7'- <br /> PHONE PHONE ❑ Site Plan approval from <br /> 7 /i/ 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: q (� CURREN Z NING: ":35:‘,i7 ❑ Elevation of property <br /> ❑ NUMBER 0✓/ D.' )if a"0�9 frontage drawn to scale. <br /> TOWNS SECTION: _ <br /> L/ /�`'f — '/e: S�" '/%5:455 5a) ❑ Driveway permits <br /> (state, county,town) <br /> ADDR ie �Q "4 4 5!-R� <br /> ®OO l��a�° ' `� G�� �� , -� ICI Sanitary permits <br /> CSM�^36 LOT SU ISION BLOCK/LOT <br /> AOF/`y (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE T DESCRIPTIOt <br /> r'as'h di- /keP1/4h 5Z'q,.- rq/fe (0)? 1?') 5 j ❑ Zoning District <br /> . '4 This 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 N M : ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBS OF STORIES: (Not including basement) <br /> ' 1, / ❑ Wetland/Floodplain/ <br /> T AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ ErosionControl permit <br /> l TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> /// U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ •-► $ ,. ? 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 jJ No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes jiii No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? tit Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 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? CI Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ ■ -► <br /> 545-112(4/08) <br />