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ZONING PERMIT APPLICATION www.countyofdane.com S U P P L E M E N T :o V A p p <br /> F-OR,MATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> •Tel n ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> HOME PHONE d 4 2 CELL PHONE Ec)E-MAIL ADD�tESSL T S S Variance(# <br /> CCg ••; `/..ZOOS G,o, • 12. , c o ❑ Site Plan drawn to scale <br /> AGENT ", _ORMATION ! 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 ❑ 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 w:.us ) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> PARCEL fronts a drawn to scale. <br /> /� <br /> NUMBER Ai e} l� ,s g <br /> TOWNSHIP: SEC ON: <br /> 1 1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C3 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 /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 5 ( ❑ Wetland/Floodplain! <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ <br /> ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 7( j TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ( 7‘ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ Q / and available options. <br /> (Please round to nearest dollar) V to G GO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 3No ❑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? I1 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) UYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,la No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -► -► <br /> 545-112(4/08) <br />