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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 /> _j0 Lt.vi (7 at,-, e l cl r?Ai 4"7"--e <br /> CI Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restricts g�q <br /> 75-6 r/5cL J' / )24,.;4 // Variance(# F% ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> -6,2 e-2_ Z 2 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> ANT NAME CONTACTOR NAME <br /> /-)v) 0` i ;7 44.q 5(',- /7/, '5‘:-1�<-«/5 cc -r, eLe 5 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3;-z/ /.,ry w e. <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> (,,O)? --76-6/,- 5-e 2 c } applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CUR NIT�ONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL ON) !J9/Z-a7;�-b12U _0 tp< 1- -- i .Z frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ' <br /> /�r "C Z-7 1/4: 5 41 14/: /11 4.1 ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 7 5"b rise, 1:4 <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> v i s - l (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> s��.s c9.,1 )40f-c L1. (...1-.3 T <br /> A Oe c k ❑ 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: NUMBER OF STO IES: (Not including basement) <br /> / 3 ❑ Wetland/Fioodplain/ <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: / r--. Et0$1QriContr0l unit. <br /> (P 0 ',/ 4 TOTAL SQUARE FOOTAGE: 4, (s�les,disturi nce, <br /> 2ND FLOOR: 3RD FLOOR: ` <br /> filling/access), <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ --► ♦ ♦ -► ♦ e v7j 0 6 and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑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'? ❑Yes ❑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 /> 545-112(4/08) 0° (Continue on Back) <br /> I 5 <br />