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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 /> l 0A7 7�] �5 � Jos of Zoning Status;CUP; <br /> OWNER ADDRESS (Number, treet,City,State,Zip) /� Deed Restriction; CSM <br /> "- i ? A i A) 5r-. M.41 1(3 0"1 6`3 9'// Var.. .-_-,...�� ) <br /> HOME- ONE CELL PHO E-MAIL ADDRESS <br /> . ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimen .• <br /> AGENT NAME CONTR• TOR NAME <br /> / 7 <br /> d4 „ . ; J I , • S A Site Plan including I An <br /> AGENT ADDRESS �11� CON -AC OR S',DRESS of well/septic <br /> (City,State,Zip) (City,State, ) • ❑ Setbacks <br /> /13 J �q 1.r e v 'r S3 , i,. <br /> PHONE PHONE / Site Plan approval from <br /> d'� �9"- c1/c-�[i, g9-17, 2_ a.•licable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> t/'6 60, /Q./S - L .1100 R Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> r _ )J hi A-) 14: /a/a: Driveway permits <br /> ADDRESS: �/ (state,county • i <br /> p °2 4r3sz_r /�n.� S� !d _ - , permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> •Ubll private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIE <br /> PROJECT DESC PION: <br /> Ss ei � l`.i— ref 04'4)-f-1) P :I'1 Zoning District <br /> ❑This project is a new building or structure. Permitted Use? e c '7-U <br /> AThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: a-t <br /> �RUral ' .®rr-Y4.. c ill <br /> ❑SEWER ❑SEPTIC (ne -xiSting / <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1-f -_ odplain/ <br /> ., «r a 0 <br /> ahorela t'• (attachment) ee <br /> AREA TO NEAREST SQUARE FOOT: Wei... CSei <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> At BASEMENT: 1ST FLOOR: ErosionContrt permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbatice, / <br /> / <br /> filling/access) ` s <br /> 2ND FLOOR: 3RD FLOOR: .3 3 i 1 Jt / <br /> y Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ --► ♦ --► --► ♦ / /]j� and available options. <br /> (Please round to nearest dollar) $ i/ c V , Q <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 2/Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ,l Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ❑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 ,fahlo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ -0. -► <br />