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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMAT'�')N CUSTOMER TO PROVIDE <br /> OWNER NAME , <br /> ► rnl %io <br /> ❑ Zoning Status;CUP;9 :S�ber,Spell, ,Sta , ip) / �� tb 1, 535707_, <br /> Deed Restriction; CSM <br /> Variance(# ) <br /> HOME; gy/� CELL PHONE E-MAIL ADDRESS <br /> C!� (O/ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> A NT NAME <br /> WC_ ME ' i <br /> 1 ed i ,f.. ..0- ❑ Site Plan including location <br /> AGENT ADDRESS r DS / of well/septic iatils, <br /> (city,state,zip) (City / /��' 53? 7� CI Setbacks <br /> PHONE PHONE t/ J ❑ Site Plan approval from <br /> 79! F9 applicable township. <br /> E-MAILADDRESS E-MAILADD SS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) <br /> PARENT PA-CEL NUMBER: C RENT ZONING: ACREA ❑ Elevation of property <br /> ❑ PARCEL �i�707.33�g� K,/ AO frontage drawn to scale. <br /> NUMBER t�� (/t./ / .�/ rJ <br /> TOWN , /) % d SECTIO <br /> pZ 1/a: '/a'/a: ❑ Driveway permits <br /> Al.,- n (state,county,to <br /> "7Oc .. 7 't! R �/ J<'( ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: /► <br /> ' 0, •f' D7 — ❑ Zoning District <br /> i <br /> ❑This project is a new buildi 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 /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionCiontrol permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> ♦ ...∎ ♦ ♦ ♦ ..� 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 ❑No ❑Don't know <br /> 2. is there 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 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 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 54e-112(4/08) (Continue on Back) -+ <br />