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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 /> rr lT Z ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,pity,Stet ,z' Deed Restriction; CSM <br /> 3 Ca VO Ilhd ) �'t V(') Mt. I V1�L 3 S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME i C.a.. 'le i/ r <br /> Or► i vials Inc. ot" Alo• /. Oth ❑ Site Plan including location <br /> AGENT ADDRESS CONTACTOR ADDRESS of well/septic <br /> 360 1rro3".'S Or *ib6 <br /> (City,State,Zip) (city,St zip) ❑ Setbacks ha_PHONE PHONE ❑ Site Plan approval from <br /> 00� — 1�>Q f9 —11S3 applicable township. <br /> E-MAILADDRESS E-MAIL ADD ESS <br /> 0/1 Cd j.014 • a, Cittaded'. /1 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCE t NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL Q3 f 010 0/��.49/_ 3 frontage drawn to scale. <br /> NUMBER / <br /> TOWNSHIP: SECTION: <br /> -Am of d t i d(e 1%: 1�41�4: ❑ Driveway permits <br /> ADDRESS: t'"l Gt j� (state,county,town) <br /> 1i Caa r0 I i vlCA Cif V V000 , h/Z & v93 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3 I W„1�` / (public,private) <br /> PROPOSED PROJECT INFORMATION Omani STAFF REVIEW <br /> PROJECT DESCRIPTION:)' <br /> l�/'flC/1L-/(��. ❑ Zoning District <br /> ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ICI This project is an addition/alteration to an existing building or structure. r-� <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (neW/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) El Wetland/Floodplaln/ <br /> I [] AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionContrO(n( ermit <br /> BASEMENT: 1ST FLOOR: LI 2� TOTAL SOUARE FOOTAGE: (slopes,disturbance <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ,f <br /> ih y Z° ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ --► ♦ ♦ ♦ ♦ $ ? Q and available options. <br /> (Please round to nearest dollar) $ )3, �8 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑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) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> S-2 '°0 <br /> 3 Z -v APPLICATION MUST BE SIGNED <br /> �v (Continue on Back) <br /> 545-112(4/08) <br /> Z <br />