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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> 4111111kPROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNF►NAME <br /> /1 qn 6 !Z. r, t o ( )..fitc-t <br /> Zoning Status; CUP; <br /> OWNER ADDRESS (NuYmber,Street,City,State,Zip)' Deed Restriction; CSM <br /> L7 X07 L DGhIA/JOtif Tr. /4.rs/4//i to S3-c--,C 9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL AD'DRESS <br /> (Oa GSS'ci6 q i 7.0?-2/ 7 — <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME _ <br /> ite Plan including locatio �.\ <br /> AGENT ADDRESS -\ CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) / (City,State,Zip) <br /> ç ❑ Setbacks <br /> i <br /> PHONE PHONESI Ian appr al from <br /> applica wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> C- U Floor plans to scale <br /> PRDPERTY/LOCATION INFORMATION (http:/laccessdane.co.dane.wi.us!) <br /> PARENT PARCEL N MBER: ^ CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ NUMBER <br /> 03(d(C)tt1.�-Q�3 R - I r mil, frontage drawn to scale,- --� <br /> TOWNSHIP•) 1 SECTION: <br /> ,4�n°L ��1 '/a: 1/414: Driv ay rmits <br /> ADDRESS: -- / ! (state nty,town) <br /> 6-C(07 L�oiuvarl T'`, �ct/'bh. //, �j(�r' S 0 <br /> CSM: LOT CO # SUBDIVISION BLOCK/LOT �(p n vatets <br /> t ) <br /> -\ , PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> �( PROJECT DESCRIPTION:,y G a r` C'. -4 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 ss <br /> LI SEWER SEPTIC qoo U L/ (new On <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> .4 wet plain/ <br /> Shore ttachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches <br /> ( ® Erosion itrOI perms <br /> BASEMENT: 1ST FLOOR: TOTAL SQUARE FOOTAGE: .(slo es.da;tuc , <br /> 2ND FLOOR: 3RD FLOOR: (p filling/access) :: <br /> Review Location Sur <br /> ESTIMATED CONSTRUCTION COST: ,♦ -4. ♦ ♦ ♦ -4. available options. <br /> (Please round to nearest dollar) $6 0,50 <br /> / <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 .ErNo ❑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? JYes ❑No <br /> 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) °1.V <br /> Q <br />