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213( <br /> ' ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1 i �T61-0 ❑ Zoning Status;CUP; <br /> OWN R ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 125-7Y OoWg R PL JS22o,v/9,- G</(., 6'35 93 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ,of-V33- o (pog-2 c--- s- • ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 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 /> Li Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER C7) g -.Zj,2-- clO tir`'; - -1, /9cQS frontage drawn to scale. <br /> TOWNSHIP: SECTION 1 1 t ❑ Driveway permits <br /> lv/i 9PLI�r-1/ g 9' %: /V a) /a/4: w E (state,coup <br /> ADDRESS: ( county,town) <br /> '75 >y P/oAigT2 if? - u N20 A-A- wf. 5-g593 <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCIVLOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> APO,T7o"v rf- ( c mo OS t ❑ Zoning District <br /> ❑This project is a new building or structure. Li Permitted Use? <br /> "This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: Ip PERMIT NUMBER: C3 Rural Address <br /> ❑SEWER ASEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER bF STORIES: (Not including basement) <br /> ❑ Wetland/Flooi plain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached gariages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ EfQSiU(1COi]trC, permit <br /> c 52 Sc tr. l TOTAL SQUARE FOOTAGE: j, (slopes,disturb . , <br /> 2ND FLOOR: 3RD FLOOR: <br /> fill'ing/access). <br /> 52' S-f' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ OL and available options <br /> (Please round to nearest dollar) 1"),-%O 00 G------ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes allo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ErNo ❑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 ONo <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 �❑,,�No ID Don't know <br /> 7. Is this to correct a violation? ❑Yes l�1No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />