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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 /> bo. 54-6-(p le-5- ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (NumbefStre t,City,State,Zip) <br /> 2 Deed Restriction; CSM <br /> JS 2-0 f%'tom,Ix-7 Z4=.�,_ C r-ti ra., r t-<;! S j 1-18 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 1' 4, c. ° f ❑ Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENFiiAME CON T OR N WE <br /> (r tit Ca,74.7,-7 1 , b ( S CI Site Plan including location <br /> AGENT A DDRESS <br /> CONTRACTOR ADDRESS , well/septic <br /> 71 2- H``'7 4, <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> &ctde (e ft ,' i S 3Sk�- <br /> PHONE PHONE ❑ Site Plan approval from <br /> ) 3; - ''' .,56S--- <br /> S b applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> C e:r€.----C.' Ch o v 4-4‘• • r-=E-"r ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus;) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> NUMBER 03 C.i o g 3°3 y C°t o A l 15- O.7,c- frontage drawn to scale. <br /> TOWNSHIP/. q SECTION: _ <br /> Aittco t e"f-°^ 0 i 3, 1/4: S 1/41/4: 3 L-: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ?j LCZ e-T, Mel 4e-e- ...,•;4.- rte'.s s Pla,,, �,..,) S 3 s 2-g <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> �!--) x ,--(E) ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> Cl SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> C3 W.etlan�od lain / <br /> AREA TO NEAREST SQUARE FOOT: SltOrelatTd (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑EmsionContrc l:permit BASEMENT: 1ST FLOOR: TOTAL SQUARE FOOTAGE: 4, , ,(s ones <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ "♦ ♦ "� ♦ ♦ <�i mac' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 12rNo ❑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? 1Z1Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? caYes ❑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 LNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes La No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► <br /> 545-112(4/08) <br />