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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> i. <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 0 n SIWrd✓► oning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Li 37-7 5-i9e I Wp / J-efo-P5 f, d J- l 575.3 O� Variance(# ) <br /> HOME P ONE CELL PHONE/ E-MAIL ADDRESS <br /> 3C3 s- 7g Sa L ' livSite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S.1-0 11 U(U e c Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o ell/septic <br /> 931 7 51`1194' 1 u/A�r � <br /> Lr,State,Zip) (City,sate,Zip) etbacks <br /> oY.(S ' 11:47 .=proval from <br /> PH NE ( PHONE I- <br /> �Q) 31--- 61-7 ( :1t=bletownship. <br /> E-M�ILADDRESS <br /> E-MAIL ADDRESS <br /> 1 t/ gef d C a l VitS-o-r—plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: MI of property <br /> LI PARCEL Q6�5/0 6110- 0 3-)a L) -� f on ge drawn to scale. <br /> NUMBER <br /> TOWNSHIP: �•{ ,J )/ SECTION: }} <br /> �dWel c le o')✓)cl5a / 1/a: 1414: ■ lir,/ , -y permits <br /> ADDRESS: <br /> Li / / . a -,county,town) <br /> Li 3 I -7 )(cG1,° ' ()lot permits <br /> CSM: LOT SUBDIVISION BLO IVLOT Kiitlry lic,private) <br /> PROPOSED PROJECT INFORMATION /STAFF REVIEW <br /> ' PRO. CT D CRIPTION: <br /> U Zonin istrict <br /> his project is a new building or structure. ermined Use? <br /> TB-This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural As' c- <br /> ❑SEWER ❑SEPTIC (new/--a I ing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /i l' _ anCUROOdOlaiN <br /> AREA TO NEAREST SQUARE FOOT: <br /> I •reland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) * <br /> BASEMENT: 1ST FLOOR: .� �,t `r t ®S •nCOrltr Perini!fit l TOTAL SQUARE FOOTAGE: 4 ,0.0 es,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: Z <br /> n, 5t:vi- , Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --► ♦ ♦ ♦ $ O - a 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 Ail No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 0 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? BYes ❑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) El Yes l No C3 Don't know <br /> 7. Is this to correct a violation? ❑Yes giNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► —► <br />