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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 /> CO O l Kc ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,C State,Zip) <br /> q 9 C Ne , • r Cr-es#- . . S n Deed Variance Restriction; CSM <br /> c...n rat r'f e� (,t�s S��b Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> c g3'/-17,o 1 o: a-la -�`ia- I-t0. dad 7a@ C o r-er. p et LI 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-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ 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 /> i� PARCEL 0111 nC]3 acf i'_ C� 4 — I b6 i frontage drawn to scale. <br /> NUMBER d� 1 <br /> TOWNS P: SECTION: <br /> I ST A-0 I aci Ya: AJ(1) 1414: SO ❑ Driveway permits <br /> ADDRESS:�� ^ ` / r r � (state,county,town) <br /> 66 V-1,e1AJCt C reS ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> 7 •.L'r■v.• L <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S I-4-.e p ❑ 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 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I a-- 1 ❑ wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 1-1 <br /> BASEMENT 1ST FLOOR: '-+ Erosioneontrolpermit <br /> 1 50 ,, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> i'S O ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) $ 3,oco <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes lia No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes (i1 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 MNo <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 Iallo ❑Don't know <br /> 7. Is this to correct a violation? ['Yes Fallo <br /> 11/7 f 0 .0?s--- <br /> APPLICATION MUST BE SIGNED <br /> // (Continue on Back) —► ♦ —► <br /> 545-112(4/08) <br /> ev � <br />