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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> • <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> "9/:1 NER NAME <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> e <br /> Variance(# ) <br /> yOME PHONE CELL PHONE E-MAIL ADDRESS <br /> / ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> f-/VI C- ❑ 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 PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 6)ob 351 9soc,-7 j C-4_ v 40 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> f Ad 1/a: 1/a'/a: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> F. P-.. ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> Cl This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER )PTIC (new/exiSting) <br /> HEIGHT IN FEET: ......rrrrrr NUMBER OF STORIES: (Not including basement) <br /> a-2/ Z ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ rt?S1t�nnvk3rittC , t�7tt. <br /> 2-7 J 0 / / y g j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR:I fiilrnglaccess <br /> o <br /> c7 / ^ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) l7 <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes .-a .Jo ❑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? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 2'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 ,ZiNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes j=kkio <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► ♦ -r <br />