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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 /> ilea)11N 9—Ser\u.. \ Q_ ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> �1 35 61'�[ A' or e�� �Z �3S7S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (o0S" '()ileij 666 3 'Kl7 ;4-1e) 62 601°11 i I Ce3W1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Li Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> Li PARCEL PARENT PARCEL NUMBER: g110--b CURRENT ZONING: ACREAGE: <br /> NUMBER O) ' .1 I° ^ gVk2 5 79 frontage drawn to scale. <br /> TOWNSHIP:p SECTION: ' <br /> f�J'T t1g1( i 2 1A: ]'- k.A.7 WA: NE ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> Li�S C` 4 A- Or "- k-AD- . 3s17S ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 1 odc I t ...----.. (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ck- .4'L�1eckf (. 1-‘0A5-e_ ❑ Zoning District <br /> VIN his 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 /> WSEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /9/. ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> T <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ <br /> BASEMENT: 1ST FLOOR: <br /> IzrosionCont�permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: [ filling/access) <br /> 89 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ / I O C,0 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 1 N° ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes lo ❑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 2410 <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 P. o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 74 o <br /> t�� APAST BE SIGNED <br /> �, b (Continue PLICTION on BacMUk) <br /> 545-112(4/08) 11 <br />