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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 /> M1 ` -ORN�1' ❑ Zoning Stat , UP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Re Iction; CSM <br /> (°2. -1 S _ ILO ` -b • . 6,4 t W i 531.t Vari e(# ) <br /> ..M PHONE CELL PHONE E-MAIL ADDRESS <br /> ti's a io.-Ccp S S-og(-45')-- <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION j CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME n <br /> q--/ -1kAMICCIA4/1/4i V (�1�5 ❑ Site Plan in ding location <br /> AGENT ADDRESS /�V1�CONTRACTOR ADDRESS of well/s tic <br /> (City,State,Zip) (City State Zip) ❑ Setbacks <br /> /S A/ VJ i SSS(3 <br /> PHONE <br /> PHONE ❑ Site Plan a oval from <br /> (c 64r-3L, applica township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor pl to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.uane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: ❑ Elevation of property <br /> ❑ NURCEL '] {-2- frontage drawn to scale. <br /> NUMBER � )'C�"x.53-���•gyp � �S <br /> TOWNSHIP: SECTION: <br /> M t A`y 25. „,0 ❑ Driveway rmits <br /> ADDRESS: (state linty,town) <br /> Cct©y- WA- T5 P-D- ❑ Sanita ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 0 (pub• ,private) <br /> 2SQ1' <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: l /c, / '� oning District❑This project is a new building or structure. ( Permitted Use? <br /> ❑This projec 's an addition/alteration to an existing building or structure. <br /> SANITARY SERVI : PERMIT NUMBER: ❑ Rural ` - - <br /> SEWER ❑SEPTIC (new <br /> HEIGHT IN FEET: i C I NUMBER OF STORIES: (Not including basement) <br /> ❑Wetlan am/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shore el-(attachment) <br /> (Outside dimensions including unfinished area, attached gar and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: D Erosion o •0$ it Cto O ,, TOTAL SQUARE FOOTAGE: j, (slopes; it. ® fnce, <br /> 2ND FLOOR: 3RD FLOOR: dC3/ '' ifing/ ssS) <br /> Review Location truey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) "♦ '♦ '♦ ♦ ♦ ♦ and available t7pti0tlS. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,� b ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ly'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? ❑Y ❑No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (le ve blank if none) <br /> 6. Is a location survey required? (see reverse) Yes ❑fj(o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes NO <br /> ______t <br /> it () ..______-- APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -∎ -► -∎ <br />