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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME I <br /> 0Wh >9E FiEii\1 ❑ Zoning s;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Dee estriction; CSM <br /> 9 4 Sa 4 S—S S _\Ys ance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS iid`)6,0S 6L3-t4- 3a bLac�.11o('s�--- ( 1,-)-(Aokcr 4 est- Si S Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S C..mc a.s dwAeA'- Scz.rvz _ , ne-l` S'a Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Si PI approval from <br /> p' able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:Ilaccessdane.co.dane.wi.usl) Elevation of property <br /> PARENT UMBE CURRENTZONING: ACREAGE: , <br /> ❑ PARCEL �d/ �1 ,� l frontage drawn to scale. <br /> NUMBER X1(``` ''��� cX 1 ' II <br /> TOWNSHIP: r., SEC I h <br /> © 1 <br /> Z 'v r 1/4: 1 ) }�1 �1 1/41/4: ❑ Drivew ermits <br /> a� (st ,county,town) <br /> ADDRESS: <br /> 4/6`'' ,-% ❑ Sanita ry rmit- <br /> s <br /> CSM: LOT BDIVISION B OC OT (pub' ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: A. Q ' \ K A <br /> v� \ ' 2 ing District <br /> 0 his project is a new building or structure. ermitted Use? <br /> This project is an additi alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural w,!+ --- <br /> ❑SEWER SEPTIC (ne exiStin• <br /> HEIGHT IN FEET: j /� NUMBER OF STORIEt: (Not including basement) <br /> //� ❑ Wetland/Ft•,-0,,,lain/ <br /> Shorel- ••. (attachme <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached arages and above grade decks or porches) t � <br /> BASEMENT: 1ST FLOOR: ❑ ErosionCo i t'mit <br /> �� O 1 TOTAL SQUARE FOOTAGE: 4 (sl es,d tame, <br /> fi) g/a SS) <br /> 2ND FLOOR: 3RD FLOOR: 4,10, ) eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -�► ♦ ♦ --► ♦ ) © /M1� and available options. <br /> (Please round to nearest dollar) 0( ' V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 0yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? l�l'Yes 0377'N <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank one) <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 /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />