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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER-NAVE <br /> O1024 r ' 0 c- S CI Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Stree, ity,State (� Deed Restriction; CSM <br /> te" J Variance(# ) <br /> HOME PHONE CELL PlIONE E-MAIL ADDRESS <br /> .e 76, S '35 6d' 3S Y- a.) a ' .'/ 4 emu+"(. eo», ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: C U TZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL /,'s.;;, - + frontage drawn to scale. <br /> NUMBER d /o 7 /2--GI3-$YISb .' fij_.� 11:2(y) l/)• <br /> TOWNSHIP: f.N SECTION: <br /> Q (j i D- IA 5 w WA: h E Li Driveway permits <br /> ADDRESS: r� ;� (state,county,town) <br /> I S ° m° , , r 5 (1 ('`� 53 ❑ Sanitary permits <br /> CSM: Lgr SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6t- 1 'tom/(; -S a /CO' / 1 c 'LL) u>1‘..,1 -Lv r 1041,-- 0 Zoning District <br /> CI This project is a new building or structure. ' x 5' K 5' Qf91or c 6.5e_ ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or strucTure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> D SEWER 0 SEPTIC .(new/existing) <br /> HEIGHT IN FEET: NUMBER OF TORIES: (Not including basement) <br /> i©o I K k D wetland/Ftoo�llain/ <br /> AREA TO NEAREST SQUARE OOT: Shoteiand (attcllment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) it <br /> BASEMENT: 1ST FLOOR: ErOSIt)rt #3i#� " <br /> In /� ,�, TOTAL SQUARE FOOTAGE: 4, ( opes,di a , <br /> l ,� filltng/access} <br /> 2ND FLOOR: 1 3RD FLOOR: 'I 'n A N` (A.)A 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -.. _♦ -i• -P. ♦ -0. ( � and available options. <br /> (Please round to nearest dollar) <br /> 1 <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 /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -+ <br /> 545-112(4/08) <br />