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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS ME <br /> ti _)�/f <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street.City,State.Zip) ` Deed Restriction; CSM <br /> /0 7 S/ � '-,7 , G"I, 5$,53 `f Variance(# ) <br /> HOME PHONE / CELL PHONE E-MAIL ADDRESS <br /> O 7 — I° dOx� 7 o 2 - 4 0'--4.` Q e- C4`' " - Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTO�R//NAME <br /> //PC?4L e ,, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS- well/septic <br /> (City,State.Zip) (City,State,Zip) ' ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:I/accessdane.co.dane.wLulsI) ❑Elevation of property <br /> ElPARENT PARCEL NUMBER: Q CURRENTZONING: ACREAGE: <br /> NUMBER 05I;--3y�-./(07/-0 fi -. 6..,q) 7 a frontage drawn to scale. <br /> TOWNNIP,. SECTION: <br /> 6/n in 3`f,5 IA: 5E '/a'/4: SF' ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: c • • _ . a <br /> ❑Sanitary permits <br /> CSM: LOT V SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT ESCRIPTION: <br /> s-kotrs a.z,..c)(4----. 0 Zoning District <br /> . This project is a new building or structure. Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address <br /> EWER [EPTIC (flew/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I; I i ' 0 Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shbr@ land (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT 1ST FLO.�OtR: F TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> d� ate$ ♦ filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Li ReviewLocation Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -► ♦ ♦ and available options. <br /> (Please round to nearest dollar) ityD 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [h'eslo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Gil o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? igYes •, o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes Jlo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# J (leave blank if none) <br /> 6. is a location survey required? (see reverse) Elves No ❑Don't know <br /> 7. Is this to correct a violation? :Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4 ) I€ f? ! (Continue on Back) -► -P -► <br /> r <br />