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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVID <br /> OWNER NAME'/, / <br /> 0 l 9(Zoning Status;CUP; -t[jam <br /> OWNER ADDRESS (Number, et •ity,Stat i Deed Restriction; CSM <br /> r75- a ' Variance # <br /> HOME. PHONE CELL PHON E-MAIL ADDRESS I e f 14,�' ci�,4/0 <br /> I a ` `e - 92 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> XSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) /d Setbacks (3/300/3f <br /> PHONE PHONE Site Plan approval fro <br /> applicable township. w4 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> g Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdarse.co.dane.wi.us!) <br /> PARENT P BE •' URRENTZONING:� ACREAGE: /'s�+l Elevation of property <br /> Li PARCEL <br /> NUMBER arOgi 2O 1— 92*-? j''-- /� 0i V frontage drawn to scale. <br /> TOWN IP: / ` / / SEC ION: ' F 1 1 C )(Driveway permit <br /> i Z© /a: /a/a: cJ r (state,coun own <br /> ADDR'-S: � t ( <br /> � 5� 11 e � ICS 6, <br /> XSanitary pe II Is ' <br /> csM: 3g/ LOT SUBDIVISION BLOCIULOT (public, ► .� --' J <br /> PROPOSED PROJECT INFORMATION STAFF REVUE <br /> PROJECT DESCRIPTION: <br /> Zoning District -' <br /> ®This project is a new building or structure. Ir9 'pi/ <br /> Permitted Use? J, <br /> ❑This project is an addition/alteration to an existing building or structu . &S TV C <br /> SANITARY SERVICE PERMIT NUMBER: l Rural A•" .-. <br /> ❑SEWER X SEPTIC (new/ sti ii t - <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not in uding asement) <br /> / <br /> 0 Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) j�,� <br /> BASEMENT: 1ST FLOOR: 1rositxtCcritt [nllt q <br /> -ago 4 TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: r� <br /> filling/access) Aft ) <br /> �. , <br /> / Cl Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: /� <br /> -+ -to -0. -∎ pei and available options. <br /> (Please round to nearest dollar) OG' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes m No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? CI Yes ❑No U yi1 <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 04Yes ❑No 2 0 66 <br /> — <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) ZO e> DO9.) <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 /> 4., t■, / 0 0 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ ■ —► <br />