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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 /> CA%" Sca/e corm a/P V f' g) ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi Deed Restriction; CSM <br /> -/5 571er./i ,A6 "b.^;✓e Pc 80x 630, 1, )Jce J- 4 62773 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> . <br /> 3-46-50206 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 14 KT 1 tetiSe vk 0(A e r- D <br /> i,:1d r ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 50.4.,4e_ et 5 (XL 0 t-iQ <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> 6 3-176 A --5-;o6 applicable township. <br /> E-MAIL ADDRESS 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 /> Li NUMBER 0611091/g (ptf,6 o e-2 V,3; frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> P(easa., 5?r( r-, COQ 1/4: ,�4,A: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 7(oa poi J Katy 47 Li Sanitary permits <br /> CsM: LdF SUBDIVISION BLOCK/LOT <br /> /r1 (public,private) <br /> /11(‘,34/ <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION: /' /� d <br /> -vi174t./44 ctrl W/iGe/V/ /'4d -1-YW d SC4'4 r..);g ly,/ ❑ Zoning District <br /> . ®This project is a new building or structure. LI Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> N/ ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 5% ci o?/ ���1- aYe�t /tee ��� ❑ Wetland/F000dplain/ <br /> /o 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: ❑ ErosionControI permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> / 2zoo filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 5'9i..■ /a 6 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► ♦ ♦ ♦ ♦ $ (Q '/2, &'O and available options. <br /> (Please round to nearest dollar) <br /> i9 H e, QUO <br /> .69 0(96.4 7c a-Q <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Li Yes LI 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) Li Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —+ <br /> 545-112(4,'08) <br />