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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> nl <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 00tc a-V■rk C &vi,e ,vus 'v - ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 1,`,31 Oo•V. J l-9 0Y. O Vl7KI3d-1/V Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (00C‘cai'l3'1 two (jO 33S`Lt'l y Ya hid `L ■.11- �, P . .AL tif Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> V-- ki-0; le1.-J0 - ,,P ` --j(rD 0 l l,v � gl 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 /> a-Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL t (Z_� �( ��, frontage drawn to scale. <br /> NUMBER O Li Co/0 41-3� I -•_5_360- �'� <br /> TOWNSHIP: SECTION: <br /> '/e: %IA: ❑ Driveway permits <br /> P4, � (E (state,county,town) <br /> ADDRESS: J <br /> V1S11 O 0..\)\-\-) -- -,,D • ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> .'1,0 a-1 ,a \ vu■, > t 3 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: c1 <br /> SC,:��.r.■� 1, G�.\n, e-V-Z-3Z \t sn 61 e ekJk ❑ 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 /> *SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ‘,,_ --\-� C1TV`t _Ve-v�`\ ❑ Wetland/Floodplain/ <br /> ( J Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ,---, ErosionControl permit <br /> ` '` 0 �O� + TOTAL SQUARE FOOTAGE: ,+ filling/access) <br /> disturbance, <br /> 2ND FLOOR: lD 3RD FLOOR: <br /> 10 VA,0 C)A 0 Ct ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: —II. -4* -► and available options. <br /> (Please round to nearest dollar) S LO 0`0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 14No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes allo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? atYes ❑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 ISklo <br /> 1 ( / (3 L(( APPLICATION MUST BE SIGNED <br /> ((� f 1 ^ (Continue on Back) —► -i —► <br /> 545-112(4/08) 1 C)o 1 l g6 // <br />