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ZONING PERMIT APPLICATION www.countyofdane.coro SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME `_ <br /> J r A -LI ,1LLt sp--4-h ❑ Zoning Status;CUP; <br /> OWNER ADDRESS(Number,Street,City,State,Zip) Deed Restriction;CSM <br /> A4q q QiA A A . •{-c�k,t�1(1-3 O(\ , c�I 63361 variance(# ) <br /> HOME PHONE CELL PHONE -MAIL ADDRESS <br /> (A.O8•Sl3•t1 t1 (tOB• (Qat. 8080 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ©Le1..,CJ1 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of welVseptic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ,2 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 /> 12a PARCEL NUMBER O1a11-11-14 15001 -0 A -I EX -10 ICI 3q-ts.ts-k 2 frontage drawn to scale. <br /> TOWNSHIP: SECTION: riveway permits <br /> Vk CA4--f �8c �t. A. `S a A/: (state,county,town) <br /> ADDRESS: <br /> A30-1 -Zt.A x Dr. S.kOUE \*o ' W i 636 V ❑ sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: . <br /> &uO honu..c.or ruc. co ❑ Zoning District <br /> . ErThis 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: <br /> ❑ Rural Address <br /> ❑SEWER .SEPTIC 5 i$Zta8 (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: ❑ ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> ��� °� filling/access) <br /> 2ND FLOOR: 3RD FLOOR: �� • <br /> • ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -� ♦ ♦ �� �� and available options. <br /> Please round to nearest dollar) f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Ei No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ErNo ❑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 RN <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -1 <br /> 545-112(4/08) <br />