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-7PA 7'-f <br /> 'ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUST R TO PROVIDE <br /> O ER NAME <br /> / ' ./ oning Status;CUP; <br /> OWN DDRESS (Number,Street,City,state,Zip) 4 Deed Restriction; CSM <br /> € L t / <br /> t ( '� / ,./ `` L Variance(# ) <br /> HOME PHONE jA CELL PHONE E-MAIL ADDRESS -. <br /> n 7 - 1 ,e*("" =--, ''-` t ,-' '.,, '',7 its Plan drawn to scale <br /> AGENT INFORMATION j CONTRACTOR INFORMATION - • includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> r e,e7- 1,' ) '. ''-? it - Plan including location <br /> AGENT ADDRESS CONTRACTOR l)DDRESS of well/septic <br /> e;'('''''', "''' ' ;.4 / ) r t✓, /QS) <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> .c t'_,6. `, / ;_ '. .., (1 I <br /> PHONE PHONE _ to Plan approval from <br /> ' ;� < ) -:'' 4. („ ;, applic ble township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: 1 CURREN ZONING: ACREAGE: Ievation of property <br /> ❑ PARCEL �LkV t tea\ -:°C;t-V ` __;1 frontage drawn to scale. <br /> NUMBER 1� \ <br /> TOWNSHIP: - SECTION: <br /> '\ (17W�" -=.( kvCk5 '/4: 1/414: ■/1! 'veway permits <br /> -tate,county,town) <br /> ADDRESS: <br /> kA n , t. <br /> V jC k., \ i \( l'1 k \ VN\: t 1 ':,i :\ , of : ) )r .■4 4,!-anitary permits <br /> CSM: LOT SUBDIVISION - _ BLOCK/LOT <br /> 41 Y-tOVL ti (public,private) <br /> PROPOSED PROJECT INFORMATION FF REVIIEW <br /> PROJECT DESCRIPTION: <br /> \7601( oni District <br /> ❑This project is a new building or structure. ermined Use? <br /> fl This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERV E: PERMIT NUMBER: Rural <br /> VIER ❑SEPTIC (new/ X ng <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) a <br /> 1i-,or etland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> rosionControl permit <br /> BASEMENT 1ST FLOOR: ♦ TOTAL SQUARE FOOTAGE: ,j, (slopes,disturb : <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: /-)2 ki <br /> 1!r'',eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -4' -0 -0 -0. -10 ��£� r and available options. <br /> (Please round to nearest dollar) <br /> - t t <br /> is within 300 feet of a stream or 1000 feet from a pond or lake? • Yes =4 No ❑Don't know <br /> 2. Is there a wetlan or oodplain on or near the props ■ Yes C■ No a Don now <br /> 3. Have you talked with the township about your project and are they in agreement? 4-Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Jiallo <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 ASJ 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) <br />