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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 /> 1)04.v,t CA 13 . c`.)Q--la'-vd ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> (Q tel So.wro 52_6.. c_dartv1-ah W t S 3 3-3 1--1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (049g -U'{ 'uti (pO8 -4342-3 o0 j c,,,Uo,,,,j,0 Le12ovx, i— ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> LI 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-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT w�PAnnRCEL NUMBER:Z.1J 1 CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER oc . O - a -J'�7-Q c f R--1 D. 79 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> PA b t b v 2 1/a: s t 1/4%: S j ❑ Driveway permits <br /> ADDRESS: s (state,county,town) <br /> Le t01 3w..000r-, 1 (rldc, r1-0 ti WS S3 S 3y ❑ Sanitary permits <br /> CSM: LOT U SUBDIVISION BLOCK/LOT <br /> on g (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE T DESCRIPTION <br /> ( Y c` t.- ❑ 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 .SEPTIC (new/existing) <br /> HEIGHT IN FEET , NUMBER OF STORIES: (Not including basement) <br /> jq,S I ❑ 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 1 ST FLOOR: 1--, ErosionControl permit <br /> Q 3 L. 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: w <br /> filling/access) <br /> c1 LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ f and available options. <br /> (Please round to nearest dollar) $ G <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes elNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes rklo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? files ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? tilYes ❑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) 'i Yes ❑No LI Don't know <br /> 7. Is this to correct a violation? ❑Yes ANo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> 7P (Continue on Back) ■ —■ -+ <br />