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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 /> I r `ELER Ov C-- cc H' LU ETC 2 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 X c?3 V1(-AS HC?L R oA) Cern&E GeavE /v, Sssa7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> C.0• 83S- 8i qc 608 112-39`f b Sctil u-a--t ex. I & w.),Lbt tp.._, n.Q-T- ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME _ <br /> ELF ❑ 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: CI Elevation of property <br /> ❑ NUMBER D 7//~/!Q-8a70-E3 R. - / , 9 frontage drawn to scale. <br /> TOWNSHIP: SECTION: ' � , 1/41/40E ❑ Driveway permits <br /> CC,774-�-E (-s' °D0 / A (-0 (state,county,town) <br /> ADDRESS: <br /> -�Ec( ` /,4- S itio PG • Ti b-6 Gri c UC 0( ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> • ' O / G o 7" / <br /> PROPOSED PROJECT INFORMATION r STAFF REVIEW <br /> PROJECT DESCRIPTION: S t�.L D <br /> G t4 R De Ili C- ❑ Zoning District <br /> 21-This project is a new building or structure. ❑ Permuted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ®SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 6 F / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> /o7 O + TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> � filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: c.9e) and available options. <br /> (Please round to nearest dollar) "♦ -'o. -♦ '-NI. "• '♦ $ 1/ Q(.7,) . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ji4rNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes W 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 Nr 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 C4 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes XNo <br /> 7 ti 0 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► ♦ -6. <br />