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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> `t W ` 4,&1 ' ► � lam''` k,r-8 I 01Q4 Lit- <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number, et,City,State,Zip) Deed Restriction; CSM <br /> Lo cz3 3 3 t \a nk DI v.rnej W,Kl i Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR SS <br /> `-Ra — i C(50 Li Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTQOR NAME <br /> t(._ - rfr Dc-KS G n d th.h <br /> .: 3 ❑ Site Plan including location <br /> AGENT ADDRESS 30TRACTO, R , RES c Q of well/septic <br /> (City,State,Zip) ( ' ,State,zip) CI Setbacks <br /> ll- ,wk 535;71 <br /> PHONE PHONE ❑ Site Plan approval from <br /> (pig 6 '39. L-- 3 L� applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ 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 /> ❑ NUMBER �to 5jj 01 10 '-5©1-(0671^g �'t"— I . 3 -1 frontage drawn to scale. <br /> TOWNSHIP: SECTION: l <br /> 1 �C' q I C) 1/a: 1/1%.S ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> t, 33 ' t\'t c*- Di'. <br /> CSM: LOT SUBDIVISION A . BLO 7 ❑ Sanitary permits <br /> • lit. O�TL ° , (public,private) <br /> PROPOSED PROJECT INFORMATION '*�G <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ 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 /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: ShOr @)arfti (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ Erosion it <br /> `a _'a 4, TOTAL SQUARE FOOTAGE: 4 (slopes,disturb; e, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: i,1 <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location n Survey <br /> —► ♦ ♦ ♦ ♦ ♦ s O c'>. 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 to ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes f 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 ci(No <br /> 6. 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 o CI Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> 0° APPLICATION MUST BE SIGNED <br /> 545-112(arva) (Continue on Back) ■ -i -► <br />