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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 /> DO001 1 6 R Bc ,r\ ❑ Zoning Statu • UP; <br /> OWNER ADDRESS (Number,Street,Cie,State, ip) <br /> qg 2 ,fie S,( s._ a, �,��C Fe IA., a S3_. eed Re ction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS aria (# ) <br /> et., 59a 093e <br /> Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION a d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Cl eC1 f`\J 6 o r p , ite Plan including location <br /> AGENT ADDR S CONTRACTO,Q j ADDRESS of well/septic <br /> 1 910 -' n Ii 54 <br /> (City,btate,up) (City,State,Zip) _ Setbacks <br /> Ocron tit i 53 S3 <br /> PHONE PHONE <br /> S SS d Site Plan proval from <br /> $b0 3) 3 applic a township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT L N MBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> PARCEL <br /> ❑ NUMBER <br /> P 4 � g� �O 1 '�, � /, 6 / frontage draw scale. <br /> TOWNSHIP: SE NG /� i 1 <br /> �n (� i/a1/a: �w ❑ Drivew permits <br /> ■ADDRESS: ' (stat ,county,-town) <br /> �(' E C'■s S 1:1 San'a its <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (p •Ii ,private <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> `la y cV, 0 'e, 1r i' r oning District <br /> Ca This project is a new building or structure. ® Permitt_ _?' <br /> ❑This projec is an addition/alteration to an existing building or structure. <br /> SANITARY SERVI . PERMIT NUMBER: ❑ ra it °Ss <br /> EWER ❑SEPTIC a existin. <br /> HEIGHT IN FEET: / Co ( NUMBER OF STORIE1 S: (Not including basement) <br /> etiandiFloodi(ain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorelantf (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) \ <br /> BASEMENT: 1ST FLOOR: ❑ r0S1011c�ntrt# nnit s <br /> �� 4, TOTAL SQUARE FOOTAGE: 4, lopes,disturbance, \' <br /> 2ND FLOOR: 3RD FLOOR: <br /> /ilIin /acceSs) ∎ \ <br /> CO Review Location Suns <br /> ESTIMATED CONSTRUCTION COST: ey <br /> (Please round to nearest dollar) ♦ "� '� ♦ ♦ '► co d available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? v Yes L5a No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? C Yes ❑ ®Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? IA Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blan i none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> � <br /> APPLICATION MUST BE SIGNED <br /> '4(545-112(4/08) <br /> o (Continue on Back) ■ ■ -♦ <br />