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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 /> l t 1 <br /> 11 I( IM C• m V ikh-- ❑/Zoning Status;CUP;OWNER ADDRESS N tuber,Street,City,State,Zip) <br /> . .-7 30 'n E I 5 3��� Deedestriction; CS <br /> M <br /> dance(# <br /> )HOME PHONE LO E-MAILA SS <br /> biA '-) T? 1-15°K--O () 0/Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION land includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> i <br /> ❑ Site Plan including location <br /> AGENT ADDRESS % . CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) ,.... r 1 ,.:.' (City,State,Zip) <br /> Ca,'Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> appliceblatownship. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ F(ooans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PAR LNUMBER: , CURREN ZONING: ACREAGE: <br /> ❑ PARCEL ( J , 10. frontage drawn to scale. <br /> NUMBER <br /> ` ( �'�J" �� �27t�' �51G� I w � '�a g <br /> TOWNSHIP: SECTIO0: , <br /> T -� '/4: 1\J �. 14144: .S E ❑ Driveway permits <br /> PICK I I�11 ,, (state,county,town) <br /> ADDRESS: , <br /> <14 7 Q. / <br /> CSM: LOT SUBDIVISION ( BLOCK/LOT ❑ Sanitary permits <br /> 11 (Pubfic,private) <br /> PROPOSED PROJECT INFORMATION <br /> TAFF REVIEW <br /> PR JECT D S RIPTION: ` , t' <br /> J:), )/ / L� vc��n S1�e ci\ — o 0� �ut I�,,A as X 16 • ding District <br /> 'This project is a new building or structure. <br /> al/Permitted Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural A less <br /> iii(SEWER ❑SEPTIC (new/ Sting ,, •- <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) •" <br /> a/ ❑ Wetland/Notiaplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' <br /> ❑ ErosionCCCmtrol permit t'\--/ <br /> BASEMENT: 1ST FLOOR: h y.�� <br /> �' Jr TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, f <br /> ( .'' filling/access) ' /:' <br /> 2ND FLOOR: 3RD FLOOR: f <br /> na S1 '1" ❑ Review L oc ion Survey <br /> ESTIMATED CONSTRUCTION COST -+ -+ -4* -P. -P. -I* I �� G-d and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? k■• Yes PfNo ❑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 )I Ng <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 lallo ,aDon't know <br /> 7. Is this to correct a violation? ❑Yes ,t No y,,r ? L I APPLICATION MUST BE SIGNED <br /> 545-112(aoe) (Continue on Back) -+ -► -► <br />