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• SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> • PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> getWiau / -S/.( -177t1Z-CI ❑ Zoning Status; CUP; <br /> OWNER ADDRESS�(N ber,Street City,State,Zip) <br /> 1 Z� W/A/n - 6Tp MAIL Sik Lt)/. 53 70 y Variance(#fiction; CSM ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> oq—Zt'/—%7t 605-L35-OZz' 1" el. ' , ,/tav1fSI/T,te7 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME 5( CONTRACTOR NAME <br /> 7O jg f e k <br /> $ Ov�e 1=1 Site Plan including uding location <br /> AG TADDDRESS CONTRACTOR ADD RESS of wellseptic <br /> .//tote_ dw.�� . 0i-Ate- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <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 ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 0710051 z `Q 3 go o—3 •i Z„ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -1& &p a Bloom ktG 6,20 lc d S 'h: Ale_ wh: ,g/W ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 3V `'7 <br /> OJ '- AtI& ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 33 3 15 /yri,,/'.C.1•G 7 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: � /1 <br /> - 14/ t€ ui( ( C57-ktie-T 0 AI ❑ 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 (new/existing) <br /> HEIGHT IN FEET: r II NUMBER OF STORIES: (Not including basement)cis <br /> `r ❑ 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) r-, ErosionControl permit <br /> BASEMENT: ^ 1ST FLOOR. 0 f <br /> (_;f� � b Y 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: �-�- � Lj <br /> � `r I �/ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: [f and available options. <br /> -• -• -• -• -•(Please round to nearest dollar) 7 3/ 6�s <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 4No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes C'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ,I Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes IA No <br /> 5. Is this project associated with a rezone/CUPNariance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) 21Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 21 No <br /> 1 S C APPLICATION MUST BE SIGNED <br /> 545-112(4/98) 0 (Continue on Back) -► -► -► <br /> c <br /> 2v <br />