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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 /> ' / I u e _ ❑ Zoning Status; CUP; <br /> OWNER ADDRESS/ Stre=,City. ate,Zip) <br /> 1 7 (' /` 6 Deed Variance Re(triction; CSM ) <br /> �3 B-�itu.?� (,, �{fL Variance # <br /> HOME PHONE 1 CELL PHONE E- AIL ADDRESS I s'.--(S>7 <br /> 'C feS41.- - Si 3 "62- 4, ke Sfie '3 r ,1.4- ❑ 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 — j 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.wi.usn J Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: p p y <br /> p PARCEL ^' (, �q /� frontage drawn to scale. <br /> NUMBER 01 b 07l/Vdk3-v5y7-y g- . /3-L <br /> TOWNSHIP: SECTION: <br /> - , Sw ,/,/: iJ _ ❑ Driveway permits <br /> ( G 01 ------ °'-- -- - (state, county,town) <br /> ADDRESS: <br /> y3 a7 am n 1LS c f- ❑ Sanitary permits <br /> CSM: LOT SUBDIVISIt BLOCK/LOT <br /> 3 Me. ) Grove- <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ,/ tty S ❑ Zoning District <br /> . This project is a new builicling or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: �/ PERMIT NUMBER: ❑ Rural Address <br /> IA S <br /> J SEWER EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 1 Li 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: i 1ST FLOOR: ❑ ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 9' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ . 000 OLD 4 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes f No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ' 'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? des ❑NQ <br /> 4. Has there been a zoning permit issued for this pro t s? ❑Yes ZNo <br /> 5. Is this project associated with a rezone/CUP/varia ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes QNo ❑Don't know <br /> 7. Is this to correct a violation? 200g ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) DANE COUNTY PLANNING&DEVELOPMENT (Continue on Back) —■ ■ -+ <br />