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. q .-IVC 1 66 r ejt-6-9' Z49 1 ; <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUS MER TO PROVIDE <br /> OWNER NAME <br /> the 1i�/� ' /70"r��`�� Zoning Status;CUP; <br /> O RADDRES (Number,Street, ity,State,Zip)I "/,J� Deed Restriction;CSM <br /> HOME PHONE �� 9 CELL PHONE/, N��-e 6 i S 3x74,1 Variance(# ) <br /> SS <br /> /,, • •3C-0/3 Co 3‘e Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> (2 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Di Setbacks <br /> PHONE PHONE c val from <br /> app�ownship. <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 ZON G:r ACREAGE: levation of property <br /> ❑ NUMBER 6�7-�g�'��j 2 frontage drawn to scale. <br /> TOWNSHIP: SECT N: *-e-way(i n 4�< _ 1/+: '/1/: permits <br /> ADD M: � , 92 D� • ���7,3_ <br /> (state,county,town) <br /> `ft/7 �L`P�i ��jl� 01 Ita ry p <br /> CSM: ermits !��4]LOT SUBDIVISION BLOCK/LOT <br /> 5-12 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PR JECT DES RIPTION: �/ <br /> Di, Z 9 V/.D. u 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 A• - <br /> ❑SEWERPTIC (new/e <br /> HEIGHT IN FEET: NOF STORIES: (Not including basement) <br /> NUMBE <br /> — 14/e and/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: horeland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �7r <br /> BASEMENT: 1ST FLOOR: , r — W�f siionControl permit <br /> j tt """ <br /> _ -��, � r�* • _-. / OTAL SQUARE FOOTAGE: j (slopes,disturban„-, <br /> 2ND FLOOR: - 3RD FLOOR: / <br /> filling/access) `t` /�fj <br /> L 0 4 Iew Location 'urvey `.�J <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ 1� � ' end available options. <br /> (Please round to nearest dollar) $ 10 boo <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 'fo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes AINo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? IaYes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ikilNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blar$,if none) <br /> 6. Is a location survey required? (see reverse) ❑Yeso ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes XNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► -0, .+ <br />