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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 /> 4S►(t I Ac n -1r / the ❑ Zoning Status; CUP; <br /> OWNER ADDRESS'Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 8.5Z t l Jin9+0 \i3c,,iri M;rld/e a \A/E. 0356Z Variance(# ) <br /> ca 5F31037_ CELL PE E- AIL�4DDRESS <br /> �OS)831-1�3�1 _ ,,r <br /> "`r.<l�tsl'�S�' �i`/iria`1 co r`' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME dba. k cc'c ec - .P <br /> ors ;nccjs; roc, /vl ad stars ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3(eO Procvss .Dr. /I to <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> (o i e Grew wT' 53527 <br /> PHONE PHONE } ❑ Site Plan approval from <br /> 6,,D2)) 8391/33 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS _'" <br /> r�'iad Son �;)U-�cliaded4.0et ❑ 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 /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER 0.32Z�7(r$ "o5 1-202Y1 <br /> TOWNSHIP: 1 SECTION: <br /> M 6∎6\2 b5 1/a: WC 1/a 1/a: !\4.1 ❑ Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> 85 55 G I 1 1.(1*. (I 0- ❑ Sanitary permits <br /> CSM: OT SUBDIVISION BLOCK/LOT <br /> 3n.: k tae s (public,private) <br /> PROPOSED PROJECT INFORMATION 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 /> �i L1 Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ ErosionControl parrnit <br /> ,1, TOTAL SQUARE FOOTAGE: ,�, (S�es,disturba ice, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ z�, 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 ❑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 /> 50. <br /> J,b_U APPLICATION MUST BE SIGNED <br /> !� (Continue on Back) —► -+ -i <br /> 545-112(4/08) lb <br />