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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 /> /�NC y �7 /� / ` -�S gi cc 6 ` - la c o 6- S-ciY ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) / Deed Restriction;CSM <br /> l geS S fr/ifti /%/ /'l S-a cc 47L0/I/ (4)-7 S -5-'9 Variance(# ) <br /> HOME PHONE CELL PHONE J E-MAIL A DRESS J <br /> 64 • 1a_ 6 i//. NA/VC ,_(, o'6/, e - / ' C os1i1- Li Site Plan drawn to scale <br /> AGENT INFORMATION I 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/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE ❑ Elevation of property <br /> ar NARCEL ,UC//3 5-4TO 0)4) /'i—/ G`0 , 8 frontage drawn to scale. <br /> NUMBER �� <br /> TOWNSHIP: SECTION: <br /> n ,e a sa it f S Pr j,iy5 t/4: '/a'/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> We-5- 5/rA A Le/I/Ad ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 6 775`y I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: pc i � sked <br /> Li Zoning District <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: A/C kt}c_ PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> )0 -r .e e I F Wetland/Roo: 1E11W <br /> AREA TO NEAREST SQUARE FOOT: ShOr @1cn(. StlChlTlenf) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ Erosion ntrol-permit <br /> �» /+� ,�, TOTAL SQUARE FOOTAGE: ,�, (slopes,disturbance <br /> IOW T filling/access)- <br /> 2ND FLOOR: 3RD FLOOR: <br /> 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ --► ♦ and available options. <br /> (Please round to nearest dollar) Q O O, (Jt� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes litNo ❑Don't know <br /> 2. Is there "W or flooOlain on or near the property? CI Yes I'No ❑Don't know <br /> 3. Have you aik"ed ith the townshipjabout your project and are they in agreement? ElYes ❑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) ❑Yes 20 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes grNo <br /> APPLICATIUS <br /> (Continue on ON BacMk)T BE SIGNED-* -► -► <br /> 545-112(4/08) <br />