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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> 31-{ S <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> TCA'I ///V.-r ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 3y�p �, Deed Restriction; CSM <br /> O ,7 j. f-L/7.56 -"1-/ ?' (-- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> , " .t:- <br /> Oz-♦ -a2( /7 66 i-: z/3-_OS ..,;"L`. °'1` Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMAVtN and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> AGENT ADDRESS CON RACTOR ADDRESS !rl/ \4\T ( �6 of wellan including location <br /> (City,State,Zip) (City,State,Zip) 0 Q,0;E'tuu Setbacks <br /> PHONE PHONE DEC ❑ 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.wLus') <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER Res;den tat- <br /> TOWNSHIP: SECTION: <br /> Rid r v '/a: <br /> 1/414: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> f more I ,' I <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> G?'Q r$q� ❑ 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 VISEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER O STORIES: (Not including basement) <br /> /S.s o " / .> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorelartd (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) , <br /> BASEMENT 1ST FLOOR: ❑ Erost�nCon�permit <br /> - 3, TOTAL SQUARE FOOTAGE: 4, (sees,disturbs e, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: I/c)/� <br /> V ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ G�� and available options. <br /> (Please round to nearest dollar) $ y <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes t o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? C3 Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes or o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years?..l-U ❑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 d Don't know <br /> 7. Is this to correct a violation? Cl Yes La 4o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ♦ -o. <br /> 545-112(4/08) <br />