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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 /> (17eGvC� P1 TTr"-`(» <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 509 3 l_A,-)c ot._-� +2 D , Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (coo 835 .8Bo/ 957- ,4-155 Cos-Tor-1D e CAaZ'- E SET <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ 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-MAIL ADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ZONING: A REAGE: ❑ Elevation of property <br /> ❑ Nunn ER 0509- I'-\ - C'>5 Z o - -I LC. I 5. a 8 frontage drawn to scale. <br /> TOWNSHIP: SECTION: 1/4: 1 1 N W ❑ Driveway permits <br /> C,ec�-� I '�; tJ� /a/a: (state,county,town) <br /> ADDRESS: <br /> 5093 (...‘,...)c o u 2.0 0e l 1.o., 53515 <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3 I o Co i (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> DECv; ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> )4This 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: I NUMBER OF STORIES: (Not including basement) <br /> -Z ❑ Wetland/Floo lain/ <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: ❑ �roS10nntr .'Cnlit <br /> —19 Q) - j, TOTAL SQUARE FOOTAGE: ,`, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: o� <br /> (Please round to nearest dollar) ♦ "♦ -+ ♦ -�P "'. $ H oc o and available options. <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 )allo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? AYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes E.J,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 Li Don't know <br /> 7. Is this to correct a violation? ❑Yes )4\10 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -. -► <br /> 545-112(4108) <br />