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/► b@. <br /> - ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> . PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Ale/9Z lD�iyD2 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,S/frj/v,'j t,City,State,Zip), Deed Restriction; CSM <br /> 70. /U6e �Y�` % ,qF ,_ /v riz,/'� za - Variance(# ) <br /> HOME PHONE CELL P ONE E-MAIL ADDRESS <br /> 5 7- Y<9/ yS= s/67 <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /90 /CAW /'/W_Icic //p S. ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ,5-7e /�WN eiz <br /> (City,State,Zip) (City,Stag,Zip) ❑ Setbacks <br /> S'L.v ,09,69,4;6 l.(ii '. <br /> PHONE PHONE ❑ Site Plan approval from <br /> 35--42 applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN'ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER a/.V89/r-29a-02 797/ f''1 frontage drawn to scale. <br /> TOWNSHIP: SECTION <br /> 8,e i:S/;G c 9 1/4: /(/z., 141/4: /u Gel ❑ Driveway permits <br /> ADDRESS: A% �� (state,county,town) <br /> °? 77� /V6,41) AFL ' ` 5 9i ❑ Sanitary permits <br /> CSM: LOT SUBDIVISMON BLOCK/LOT (public,private) <br /> 3 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DES RIPTION: , C J <br /> ,e 7- 4 /oX,aqd oLiiii16-/ <br /> 7/ ,51.22 6)/7/2), ❑ Zoning District <br /> 54 This project is a new building or structure. ❑ Permitted 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 /> // ' 1 ❑ uvetlanooIaiN <br /> i Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ <br /> BASEMENT: 1ST FLOOR: T` Erosl C''on l'permit <br /> '7,""l TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> C2)- 0 filling/access)2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ $ �6,0G) and available options. <br /> (Please round to nearest dollar <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes A No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the prop rty? ❑Yes Ia No ❑Don't know <br /> 3. Have you talked with the township about your proj ct and are they in agreement? ❑Yes C3 No <br /> 4. Has there been a zoning permit issued for this pro erty 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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 14No <br /> APPLICATION MUS BE SIGNED <br /> (Continue on Back)T ♦ -► -► <br /> 545-112(4/08) <br />