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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 /> -i5 R,j V 1&Q\n! ■e i c 1\A5 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Streit,City,State,Zip) <br /> cI f D (' 6Ao Y E r) Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Lot;' - ..... ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME /n� CONTRACTOR NAME <br /> Lv <br /> CJlc L( S. �-t S v- u.�y 5 ❑ Site Plan including location <br /> AGENT ADDR SS CONTRACTOR ADDRESS of well/septic <br /> 18 C_fno.c Lr 1--in <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> S -c, k trrI-e ic> LOT 3,b 9 <br /> PHONE Q PHONE ❑ Site Plan approval from <br /> Lees- a' i -i - ( 3-7-7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpa/accessdane.co.dane.wi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL [9 �^ frontage drawn to scale. <br /> NUMBER oas/ a ou,10- oa-ct ow-3 of <br /> TOWNSHIP: SECTION: <br /> '%: 1 1 ❑ Driveway permits <br /> ADDRESS: ti 1 ti /4/4: S ( county,town) <br /> state,coun <br /> q q Cr(Aar I--v‘. ��+CU.C444 t. V,,�c 5 r3 J�S c) ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> I D I< (O S 1/4r\_+LA ❑ Zoning District <br /> a 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 /> t a ❑ Wetland/Floodplaird <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionControp�ermit <br /> /00 <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturb nce, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> / 110 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: 5G� and available options. <br /> (Please round to nearest dollar) —.• -40. -0. ♦ '■ —ii. f ' <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 ❑No ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> 1 <br /> 5 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —* —► <br />