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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> i � � <br /> e--/ 0 `L a f ` �=-- ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City)State,Zip) pp Deed Restriction;CSM <br /> „..5_„—i l C'1. r�� � 1�1a�td�1P >> i I _j3i Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> hC'-, L' ( /'\o r- I ,` , 11/41e_ iv i wL K j ) 1` ❑ Site Plan including location <br /> AGENT ADDRESS J t-� 11 CONTRACTOR ADDRESS of well/septic <br /> i i q C_ ht, rc1, .5) [ `t C ka; rc_l1 R <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> / `1 i A C (�tZ :L (k)/ .s 35�1-.. /`I ) ack le c, 04--, i n3g2---- <br /> PHONE PHONE ❑ Site Plan approval from <br /> 0 g` 4-3 8 - 7 1-3 Z 6 o 8 - g 3 - 7 3 I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> o ) ,_ 0 <br /> - - d Yt _c_ v,,._ , 6.1 _1 , c__-t- ❑ 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 0 q6 S- 2E1 `0,1)- A I F7( , frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> s' Y-; ,t -F-'1. , 1%: 1/a t/a: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> .6---i / ? c 1-. 1, 1--e___1., ) / 1 1 I v i i .r1 <br /> ` ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ,_,.- c- 1-- e ,L_ ❑ Zoning District <br /> lJ 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 FE T: NUMBER OF STORIES: (Not including basement) ❑ Wetir']rit <br /> 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: <br /> Q ErosionControt: rnit <br /> 2_ > 1 4 TOTAL SQUARE FOOTAGE: ,& (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> 1 6 2_---- ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ --► ♦ ♦ ,e,v and available options. <br /> (Please round to nearest dollar) 5, CMG - <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 12 N . Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? CI"s uNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? UYes ❑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) FYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ©No <br /> ; Z <br /> i APPLICATION MUST BE SIGNED CT) <br /> 545-112(4108) (9 ) (Continue on Back) <br />