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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTO ER TO PROVIDE <br /> OWNER NAME <br /> Andy walker- oning Status;CUP; <br /> ERADD SS (Number,Str t,City,Stat�e)Zip) Deed Restriction;CSM <br /> S y �t pJ-( Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 77 0 -7 0 I-S1'ie Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State, backs <br /> PHONE PHONE ❑Site n proval from <br /> a • township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor pl scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) vatlon of property <br /> PARENT PARCEL NUMBER: CURB NTZONING: ACREAGE: p P rty <br /> ❑PARCEL ,^ Oa& frontage drawn to scale. <br /> NUMBER oC i, tStJ3 �e — <br /> SHIP: 0611 'as c toil SECTION: <br /> Sv ,�a: ,/4,/4: ❑Drive - •ermits <br /> DRESS: (s - , -•unty,town) <br /> X:: O StOJ :o+- Or ` <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sam,: rmits /)/4 <br /> `41t p (pu• c, •rivate) YYY <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> R /tee /�9Y1- COYv ir.n �,19eh pro onin istrict <br /> . ['This project is a newbuilding or structure. 1- c+1py fQ ,1 rmitted.Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> '•EWER PEPTIC WO. (new/ <br /> HEIGHT IN F ET: NUMBER OF Enot including basement) ''l � <br /> ❑ Wetland o p "�t _ <br /> - - (a ment) "� <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1STF ❑ Erosio On I permit <br /> TOTAL SQUARE FOOTAGE: j (slopes , urbance, / V C o f <br /> fillip acc <br /> 2ND FLOOR: 3RD FLOOR: g s) <br /> S53 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available op ns. <br /> (Please round to nearest dollar) �j <br /> ly <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? C es ❑No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? la es alo ❑Don't know v <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? r0 es ❑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 o ❑Don't know <br /> 7. Is this to correct a violation? [Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4108) <br />