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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 /> DAV iiL 1 'T CI Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed OP 75', / E...4 vNSA 7? / S-70,k�,�70� GA i7 535E 9 Variance Restriction; CSM <br /> Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> G01•ao ' J/, G✓. —,../E�,)\/ A i/OO 0"9 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 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.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER oi/6/0 67/-3a/=476-/ - -2 , t5-4 <br /> TOWNSHIP: SECTION: <br /> 7i-E/C QrU S7k.1N6s• 3a 1/4: Y41/4: Cl Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> 25-9 KE4o,Js4 mac/ S-A5u G he�a,•> 6.-1g ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> u r-t <br /> Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> [4 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ (new/existing) <br /> Address <br /> El SEWER 1:1 SEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑ 1Netland/Flov lain/ <br /> AREA TO NEAREST SQUARE FOOT: ShoXelarl€i"(attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ErostohContrfl'permt#, <br /> /v (C) / /9- 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> v filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 273° <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) �O 00 o <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 41No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 1pl No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? sei Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes SiD No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) rr(lleave blank if none) <br /> 6. Is a location survey required? (see reverse) 1151 Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ll�'No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -♦ <br />