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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1 � �O <br /> J ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 902 l MC*'% -'Oat 2d• variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 1.0 ' ms-r-ies 1 I,— I 2-2. ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State.Zip) (City,State,Zip) Cl Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Cl Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 2.f 4%4,_Q • S frontage drawn to scale. <br /> NUM <br /> TOWNSHIP: SECTION: 1/41/4: ❑ Driveway permits <br /> }.`r"'/� /a. (state,county,town) <br /> ADDRESS: <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> I CP OI s+DAC Esf. (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: ShOreland,(attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 1 q Z 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: q filling/access) <br /> 192- ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: 3, �av and available options. <br /> (Please round to nearest dollar) - - <br /> (01-1 <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 l .No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? C Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes <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 gl.No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 1/1No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► —, -► <br /> 545-112(4/08) <br />