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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> { PROPERTY OWNER INFORMATION <br /> CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Ge rc A S I l i r 0 r e se.pi XZoning Status;CUP; E" I <br /> OWNER ADDRESS (Number,Strree�et,City,State,Zip) ` (� /� I. I Deed Restriction; CSM <br /> I1S3 /► I (;r+i1n•cUt LIE2, RS CPO SS C O.itkS (1-)l Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS -7 3 9 2.- <br /> (3C k 161P 3 i lctk .)•DS'3/4 ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite Plan including location <br /> AGENT ADDRESS CONTRAC A ESS <br /> -1\1-•!:d well/septic <br /> (City,State,Zip) (City,State,Zip) etbacks 6'...3// t) : '/9 <br /> PHONE PHONE ite Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS \ <br /> ' loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) -vation of property <br /> PARENT PARCEL NUMBER: CURRENJ/ ONING ACREAGE: P P rty <br /> u PARCEL C)Qn�Q7Li9oS(� ]/ •_ 1 I • 6 rontage drawn to scale. <br /> NUMBER v`,� V /L / <br /> TOWNSHIP: SECT_ION: <br /> '/a: '/a'/4: Iveway permits <br /> state <br /> ADDRESS: ,�I� J <br /> state,coun�+town) <br /> '77 '0144A5-,,''4 /24 1 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF - . , r Z N <br /> PROJECT DESCRIPTION: <br /> 41 Zoning[ ',.trict <br /> ❑This project is a new building or structure. Use .. 0 <br /> �Permitt-• Use? r- <br /> ❑This project is an addition/alteration to an existing building or structure. i <br /> SANITARY SERVICE: PERMIT NUM ER X Rural `• ' <br /> ❑SEWER ''SEPTIC (ne -Xisti • <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Wetland/Floodplain/ <br /> Shorefand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) . <br /> BASEMENT: 1 1ST FLOOR: <br /> 1i' Erosit)t Controlpermit mi( <br /> /� <br /> /x� O� 4, TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> q fil�lti <br /> 2ND FLOOR: _.> 3RD FLOOR: <br /> --)c 6> , <br /> eview c a tor> Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> -♦ —► ♦ —► —► ♦ and available options. <br /> (Please round to nearest dollar) $ � ��Q 19) <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 ❑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? ❑Yes ❑No <br /> i -)- <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> T (Continue on Back) ■ ■ —► <br />