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1 <br /> - ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> . PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ik‘A'Z 4 .l��A/�� U Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Stre t,City,State,Zip) /� Deed Restriction; CSM <br /> 78 ,44,ea Wy ./ , 6 /I$$, ,q/` _c,,v, /ifiZ✓'6 2 ' Variance(# ) <br /> HOME PHONE CELL PliONE E-MAIL ADDRESS <br /> ' 7- '/s 9/ V.3.-- 5/67" ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /9/,,e/einf',/ /i'/L��c ,e4le - ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS / of well/septic <br /> $-7d Z.%VN6/Lla' ,O/L <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> a3S -4 2 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 /> ❑ NUMBER 71/99//- 2-02 797/ / -/ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /3,e,S/G ol 9 1/a: ,4/ 1414: W ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> a 7 r-7Gi' /1,P /',ass, c <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / ✓ <br /> �,e 7-4 /�?X 024 /.�C`TG/✓¢'//-/LAmc Zoning" �/'2f�G ❑ Zonin District <br /> 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 /> IN FEET: NUMBER OF STORIES: (Not including basement) <br /> // - ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ Erosioneontroi permit <br /> BASEMENT: 1ST FLOOR: (slopes,disturbance; <br /> ,l TOTAL SQUARE FOOTAGE: ,` <br /> 2ND FLOOR: 3RD FLOOR: c7}- lo <br /> filling/access). <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦♦ ♦ ♦♦ ?tG 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 Ai No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Ia 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 ❑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) JA,J Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes JNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ ■ —► <br />