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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 /> ‘r ( o'y A4 file f 7 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Sg/Q G oe- i4 life-! T r Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> - , $ 3/3 4,010 o�D' -5;)3'5- ❑ 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-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) CI Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> '/a'/a: CI Driveway permits <br /> ADDRESS: (state,county,town) <br /> 5-q/z6 0 C4jh dfrs T r /14r5411( [iri/ 5"3 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> t 42, ,r 2 �D�=� � ❑ 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 (r)SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> )Z ' ❑ WetlandlFloodplain/ <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: <br /> Erosion C'3rltrQl 3errrttt <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) ♦ $ 5, <br /> ER) <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? EiYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 4No <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) gYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -4. -i -► <br />