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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 /> 0 v er ti /1/(a l €1 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip�j d , Deed Restriction; CSM <br /> S$ ejvZ G j 14i- lY � o �,,. / i' 6-3S,),P Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> D96-3.2 9 S'3. t ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> J e r6),,zi . 6 i //if ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> I 6-O9',64,t 7 t G. t /(o G--t. <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> i,C,Jcs U.eiL./A -e W1 s3SQ'2 <br /> PHONE PHONE ❑ Site Plan approval from <br /> (o'- ol d U - y Ye / applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> G . e 1 G Td -, ,{, e7' ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us') <br /> PARENT PARCEL NUMBER: 9a/6_0 CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER ()sag, -i 'G- <br /> ' ( frontage drawn to scale. <br /> TOWNSHIP: SE TIO N ❑ DflVewa permits <br /> S POP /Vs F e,.1 di ± � • ,/a: '/41A:Ai W (state,county,town) <br /> ADDRESS: <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:i / <br /> / P I— 0 yl ...a 0 Zoning District <br /> '.This project is a new building or structure. <br /> ❑ 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 S7 3 � <br /> (2 ' (new/existing) <br /> HEIGHT IN FEET:^ O / NUMBER OF STORIES: (Not including basement) <br /> !QC) / ❑ Wetland/F odplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENTS 1ST FLOOR: ', ,L t <br /> ❑ ErdsionCrol permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (SfO �eSy CtIStUCbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FL OR: 43 <br /> (D 6 s `' l ❑ Review Location Survey <br /> ZATEDCONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ r. and available options. <br /> (Please round to nearest dollar) $ 30d jD <br /> - NISI <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ia No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes ❑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) ❑Yes ❑No Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -4. <br /> 545-112(4/08) <br />