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ZONING PERMIT APPLICATION1www-countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS AME <br /> A/v"c-; ./is10 r�s'ae,..) ,�6 Zoning Status;CUP; 4 —1 <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 77c' r'�'A,�� G Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> -O,' 23S`n-73 I72/et/is ROL1F/Z 2 ) 1' ' 'tea— r4111 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions ^� <br /> AGENT NAME CON "•CTOR NAME S <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks /l� C S' <br /> PHONE PHONE 'Site Plan approval from <br /> I <br /> applicable township. 4�� <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT 1'•-CELNUMBER: CURR:NT ONING:�-y ACREAGE: AgElevation of property <br /> ❑NUM ER P/2- —7 Y3- 72-30-/ A —16.`r 3 , g,3 frontage drawn to scale. <br /> TOWNSHIP: /"� J SECTIOtNj• 1, <br /> ./1 G t v-r a Ci e1 1? / %a: c wit:3' t Driveway permi <br /> ADDRESS: (state,county, own <br /> CSM: LOT SUBDI ISION BLOCK/LOT Sanitary • -- -cliar <br /> �— �_ (publi <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> �V t 3 x 2 �Q /J� ,•- 0 gZoning District /�--1c/ <br /> . ['This project is a new building or structure. ,4./ k io 571d ivv, Q ,I.Permitted Use? i' <br /> This project is a addi ion/ Iteration to an existing building or structure. 5 ^4-e+ = .74 as-i. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural A,-•. 5 i a <br /> EWER XEPTIC (new/• IStln• <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> (? tl oodplain/ < 2 <br /> horrPland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) roSlonCOntrol permit <br /> BASEMENT: 1ST FLOOR: <br /> O4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, t7 <br /> filling/access) 1 2ND FLOOR: 3RD FLOOR: 600 <br /> t Revlew Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available options. N� <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ �P v �//4-- <br /> 1. The property is within 300 feet of a stream or 1010 feet from a pond or lake? ['Yes ❑No DDon't know <br /> 2. Is there a wetland or floodplain on or near the prqperty? ❑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? 1,...� Dyes ao <br /> \ <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) �� a (Continue on Back) -► -+ <br />