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- ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> ' PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW R NAME <br /> i<ob PK f Cie rel-P-1 s ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) g <br /> \/ ( / '9Q v P / 1 / `�'/'� Deed Restriction;CSM <br /> HOME PHONE 3 I- CELL PHONE , '/ E-MAIL ADDRESS <br /> f,Qkpc- ~T ��S p9 Variance(# ) <br /> •_6. -- ' •'i ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME COATRACTOR NAME <br /> 1'..Dc b ( 'P� r s ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR D RESS // of well/septic <br /> �O f C�aQ� �5� Viii ❑ Setbacks <br /> (City,State,Zip) -)K, <br /> (City,State,Zip) / ' TJ <br /> l.Ci Gt C-4-1 or b.P c' U/JG 3 / <br /> PHONE PHONE LI Site Plan approval from <br /> C,10 g g y 9_ p f 9 9 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ 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 !Q �' /, 2 �9/� 3 /s frontage drawn to scale. <br /> NUMBER / 7 J /b f7 <br /> TOWNSHIP: SECTION: 1/4: 1/41/4: ❑ Driveway permits <br /> q e �� �tv SGcJ (state,county,town) <br /> ARI -� <br /> 9 Is Li tOU f/ yw7 � ! a wn � D 4'Y e LI Sanitary permits <br /> CSM: LO SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:7/4 r (j._'c 2 eo AO c`se 1/ O > Q ❑ Zoning District <br /> IolThis project is a new building or structure. 1/ <br /> ❑ 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 /'/7/// (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> C t / '1 ❑ W'etlandlFio0Vain/ <br /> Shoreiand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionC tntral permit <br /> BASEMENT: 1ST FLOOR: 1 TOTAL SQUARE FOOTAGE: 4 ($ ta,Cl� cep= <br /> ♦ fi lling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3 n 4 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ..+ --0 --► --0 ♦ $ I and available options. <br /> (Please round to nearest dollar) C <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 /> APAIST BE SIGNED <br /> (Continue PLICT on ON BacMUk) <br /> 545-112(4/08) <br />