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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ]��n^ <br /> OW R AD R SS (Number,St t,City,State,Zip) CI Zoning Status; CUP; <br /> Deed Restriction;CSM <br /> 9 f b Cv.0..e1�s t_A 54-cuq h}-o r W x- 536E9. Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> •pg'-g73-"7 7025 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> '.,4e-r 1 5 AS NI us ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 8I$ c\c.o -l-es Lv\ <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> 5-VougltiNor\ V)N- 53S-89 <br /> PHONE PHONE ❑ Site Plan approval from <br /> (DDg- K7 7- / 37 applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER aq$/eblo-2-ba-9006- 3 R y S . frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> lb;,n rx aZ fo 1/4: N IA 1/41/4. 5(Ai Li Driveway permits <br /> ADDRESS: (state,county,town) <br /> 73N Oat Its Lvx 54-0 vgt` -orq w-T 53589 <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> 00.7 ms <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> In2)( 16 5\I c . ❑ Zoning District <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> CA SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland Floc lain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> Li BASEMENT: 1ST FLOOR: I"r0$IO!iQOntrC -permit <br /> I oo 4, TOTAL SQUARE FOOTAGE: 4, (slopes,distutaivae, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> /00 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ; Q and available options. <br /> Please round to nearest dollar) , <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? Li Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Li 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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Li No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />