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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW EME <br /> i C -' '/� <br /> Al A 'h l ,45 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> I Deed Restriction; CSM <br /> _.5-4 0 G, /0 aN 7'aIa/e SL /14/9/ L S?/i 11x Variance(# ) <br /> HOME PHONE CELL PHO E E-MAIL ADDRESS <br /> 4/6/6/j ''Og ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAyIE CONTRA/TOR NAME <br /> /<e.-0/€r C--15 h454 S ❑ Site Plan including location <br /> AGENT ADDRESS CONTRA TOR ADDRESS of well/septic <br /> f i b Q' J U /� S n ❑ Setbacks <br /> (City,State,Zip) (City,State,Zip) <br /> CILOS5 P -29-AI 5 1/I/ <br /> PHONE ` PHONE ❑ Site Plan approval from <br /> o Si T, g-'/ 7 7 1 s A e 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: CURREN 1 ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ <br /> NUMBER 07 O ?.2 03-'//y/-0 A 2 s g frontage drawn to scale. <br /> TOWNSHIP: / SECTION: <br /> M T? b (�T��/v 0 4: 5 L✓ 1/4./a: Sy✓ ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> CSM: 3 7S 3 LOT Cal/At ��\suBDIVISION `� BLOCK/LOT ❑ Sanitary permits <br /> ) (public,private) <br /> • SP'; ro)/Wti/ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning 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 5 cw1 03 J 2/ (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /c1- ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ Erosion C. ntrcl permit <br /> BASEMENT: 1ST FLOOR: 1-i TOTAL SQUARE FOOTAGE: ,l, (slopes,disturbance, <br /> 2ND FLOOR: 3RD pOR a filling/access) <br /> 'D 9 S I -2 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ c. 0�7 and available options. <br /> (Please round to nearest dollar) <br /> I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes li NO ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes -tallo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? -E'Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ,2No <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 ,, 3'io <br /> 3 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) ✓r (Continue on Back) ♦ —► —► <br /> 14 f <br />