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, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW ER NAME <br /> OW <br /> NER ADD SS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> Deed Restriction; CSM <br /> 7 1 /5- fly- // 3 - A )j Q4 r Variance(# ) <br /> HOME PHONE PHONE E-MAIL ADDRESS <br /> pig c L F i <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRikCTOR NAME <br /> 7--- .cy /2 ...11.-.4, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTy)f(ADDRESS �/ of well/septic <br /> N/S- d a it d PI- t lr <br /> (City,State,Zip) (City,State,Zip ) r ❑ Setbacks <br /> II (Al c39 I <br /> PHONE PHONE ' - ❑ Site Plan approval from <br /> 6 p I-6 - r - 414-51-1- applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wii.us!) <br /> PARENT Pv AARCELL N UMB ER: CURRENT ZO I IN : ACREAGE: CI Elevation of property <br /> y <br /> ❑ a?o /Gi (g ej oy -- - ito frontage drawn to scale. <br /> le. <br /> NUMBER <br /> TOWNSHIP: SECTION: , 141/4: ❑ Driveway permits <br /> �� l�' /a: L� /�!� (state,county,town) <br /> ADDRESS: .- <br /> / /3 / i / 3 , �""` �'('�-L ' ❑ Sanitary permits <br /> CSM: pY LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> CNI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER a SEPTIC (new/existing) <br /> HEIGHT FEET NUMBER OF STORIES: (Not including basement) <br /> 11 eryi„/.., ❑ WetlandlFioodplain/ <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: ❑ 1 rosionContro permit <br /> j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> o g d� S'f' <br /> dd # ' <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location Survey <br /> ♦ --► -i ♦ ♦ ♦ 6 and available options. <br /> (Please round to nearest dollar) / 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Callo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Q,No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? aYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Cld 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 at No <br /> 60 <br /> �U APPLICATION MUST BE SIGNED <br /> 545-112(4108) / (Continue on Back) <br />