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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 /> boil%%.) 1M APSL,,.s, I�roi3.;�—S c* ['Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State(ip) Deed Restriction;CSM <br /> � d) ( I j #oSot- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> -ZA -79 7 I lN G4:.w I v <br /> &,-.-„:1.(am. ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> ----4P6 v) vINbCRS U IA 2__ �L /t):tA. - (12-$ ❑Site Plan including location <br /> AGENT ADDRESS CON) TOR ADD S of well/septic <br /> e )°)b aab)► 5+ 4O a(y ).' 3 <br /> (City,State,Zip) (Cit_yrState,Zip) ❑Setbacks <br /> k,J t S35 '3 n,.�, t,.a 5 3 ")3 <br /> PHONE PH N ❑Site Plan approval from <br /> ��8 - Zl Z — Z� --�(� 5 ,....::::1_),....0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> (711hQ»J7_ qb rOCi ,p z F3v;II);vts ,6,_,v_.,, ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: <br /> NUMBER °34 -d 2.3-$0o1-c )-I -5, Z frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 02l2 tvlcal ; f� y4: /1/. El Driveway permits <br /> ADDRESS: (state,county,town) <br /> c'fbtT) Lip' 11/.,,`,r s ter., )ZA, <br /> CSM: LOT SUBDIVISION BLOCK/LOT ['Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION 3TAEF REVIEW <br /> PROJECT DESCRIPTION: > _ <br /> 1- 2 - L5 r"i 6 ❑ 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 /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET r h NUMBER OF STORIES: (Not including basement) <br /> ct r — )()) -- 1 ❑ Wetland/Floodplain/ <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: <br /> ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> Z-3 S ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► ..4. ♦ 0 and available options. <br /> (Please round to nearest dollar) 6 �(�(� <br /> Z Z L.. 1-(D <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes l]No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes -"FiNo [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 UNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ENo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► -* <br />