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- ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME p---- <br /> ' 'c' �\ GG'C y ` J O��(1GJ() CM ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State.Zip) ` <br /> 3'- W e b �p v �A, ' Deed Restriction; CSM ) <br /> "� ` , �-��� WT. �3�' � Variance # <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60$—Ztty-1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> n"pc g- sINA ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACLOR ADDRESS of well/septic <br /> 34,t wk 'A\ —f <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> rim),k :)-(. ■ U - j4- 19- <br /> PHONE PHONE ❑ Site Plan approval from <br /> ©O L-D(sS- 9CJ t applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> (_,t-0-. O e&. l,ig'),.R( ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> PARCEL Qri 1Q5 1059'3 frontage drawn to scale. <br /> NUMBER O <br /> TOWNSHIP: SECTION: <br /> `B\p \\,18 CD`( per{ ,AL prj 1/4: '/a'/4: 1,4 E. ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 34`c\ W�1- . ; �- ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT 3%.% <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> P c J\\1� lo Zoning District <br /> . ❑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 NUMBER: ❑ Rural Address <br /> 6 SEWER ❑SEPTIC VA' (new/existing) <br /> HEIGHT IN FEET: t NUMBER OF STORIES: (No including basement) <br /> 2 N ❑ 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: ,---, ErosionControl permit <br /> Wr 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> • <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> s__. <br /> , ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -0. ♦ ♦ ♦ ♦ 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? "o'es C No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑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? 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 Li Don't know <br /> 7. Is this to correct a violation? ❑Yes X.1 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) –► –► —► <br /> 545-112(4/08) <br />