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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> R NAME <br /> 0110/ A.) ejSOr) ❑ Zoning Status;CUP; <br /> OWNER ADDRES m r,Stre t,Ci te,Zip) ` (_ <br /> 3:21_041 { I~,1G n( -�n e1 0 S4O �4Q rl (ALT 5 Deed Variance Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRES <br /> Y?? - Cog-/‘0 36- -°2'-) I ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> NT NAME COAITRAiCTOR NAME <br /> Au-, A A. ,1 j j�n 1,,�bw1„J (c, eagt t -/r«c�,45, Zvc. ❑ Site Plan including location <br /> AGENT ADDRF CONTRACTOR ADDRESS of well/septic <br /> 3339 k�`.. \ nn va, VS hlwy sue/ <br /> (City,agte,Zip). a\\ (City,State,Zip) ❑ Setbacks <br /> P NE v (Ce<<) PHONE f ❑ Site Plan approval from <br /> 66?) 358-c 77 (`og g?g _ 3y 79 applicable township. <br /> MAILADDRESS (( E-RFAILAb6RESS <br /> R:L yob'' I: W'far. I1Gt R' ■ !as24S '4 4Iwo- Le-v% ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.w9.us/) <br /> PARENT PARCEL NUMBER:(� CURRE ZONIN ACRE E: ❑ Elevation of property <br /> ❑ NUMBER 0 Y 1 0j 3� 1 ^ 960 O `0 1' I t )( � frontage drawn to scale. <br /> TO SECTION: <br /> tatr�Ii\ NO __ _ 1/a: S� 1/a14: SW ❑ Driveway permits <br /> ADDRESS: `\`� ` `` (state,county,town) <br /> 3a( 'i <kTla►1G �ann d S\TXJC Ai-0A WS 635 <br /> w CI permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:11-,, //__ t\ <br /> tt -4 ,,c, Uc.,rc. e- Ae, 4-\2 14ps.Se ❑ zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing--b ' ' <br /> SANITARY SERVICE: PERMIT NUMBER. U Rural Address <br /> ❑SEWER SEPTIC c f6 a/ (new/existing) ;. <br /> HEIGHT IN FEET: ,. • : - : - :- -. •. Inc w ing basement) <br /> �y ❑Wetlandl aodplain/ <br /> AREA TO NEAREST SQUARE FOOT: / Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ Erosion cantrc!permit <br /> CM%)L $4.cc Yeo Fi. f {� •, TOTAL SQUARE FOOTAGE: j (slopes, balice, <br /> 2ND FLOOR: 3RD FLOOR: <br /> ' <br /> filling/access) <br /> , <br /> WO *' Fit' El Review Location:Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ 1 06 and available options. <br /> (Please round to nearest dollar) /$ (Oa CO(' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? CI Yes Ai No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes NI No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes Cii No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes II 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 ki No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes (4 No <br /> 36 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br /> � � , OU <br />