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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 /> TI(Yl Foul«'-C- ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City.State,Zip) <br /> Deed Restriction; CSM <br /> 1x538 SOhufY1QQ-h er Rc'. t.) O,k.krux_Ke , LOA 5359'1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 595`3')rJ t1 m-Gu 1 Ker C hokracti I as ❑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) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY'LOCATION INFORMATION (http: accessdane.co.dane.wi.us ) <br /> PARENT PARRCEL(NUMBER 9900-8 CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL <br /> UMBER 6 I 0 '-,1j�j2- L C.— ,�- q, f frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> V 1 ex rt 0-- 33 in: , '/a'/a: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> to 53? SCh urYtaCh_o.r' ed. Gettuula..(Gz.:z , Lot 53 5q r) . <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Born Dew l ❑ 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 /> EWER FIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> Irk ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: I—, ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ` filling/access) <br /> 1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -4. $' a0 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? [Yes EINio ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Dlo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement?-- Yes [lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes j4o <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 alo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Olo <br /> 11 COQ APPLICATION MUST BE SIGNED <br /> t.b" O (Continue on Back) ♦ ■ -i <br /> 545-112(4,e8) <br />