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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 /> kgrAl g tm AlJefty F(? cT�A.1 C I/ ❑ Zoning Status; CUP; <br /> OWNER A DRESS (Number,Street,City, te,Zip) Deed Restriction; CSM <br /> /74! 2� Sr /0f-(fit. t A47i, ndi t' <S 'y,e4 Variance(# ) <br /> HOME N CELL PHONE E-MAIL ADDRESS <br /> II/ a A e <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME T� <br /> fe) 19P0"GwSo*1 -.7',jeix:60 �, Bo i to,5q'i 8,�,❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDR S "F of well/septic <br /> ��J MARI C Or? 4.. i • <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> t. <br /> mi- J,LaRk5 ct4 Z S3$z? / - <br /> PHONE PHONE ❑ Site Plan approval from <br /> 10‘' ! !'ca t• / r applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> FD a?' 0 , ;.-cAr- • h-`r /• t Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZONING:464—t ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 0-712-2,9Z- loci 0-0 E�LJsr 7640 frontage drawn to scale. <br /> TOWNSHIP: S TION: <br /> '/a: Ya'/a: CI Driveway permits <br /> ADDRESS: (state,county,town) <br /> 12 SS OI..SfAO RD <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> i b CK} z (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> R 119 Ale-u, I/prh,f ❑ Zoning District <br /> .This project is a new building or structure. <br /> ❑ 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 121 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> On E CI Wetland/Efoodpiain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ Erosion Cntroi, rmrt <br /> 4, TOTAL SQUARE FOOTAGE: 4. (slopes,distur ice, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) `�tii <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Li 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 /> 545-112(4/08) <br /> (Continue on Back) -o. -+ <br />