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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 /> Ml `,O}kN Di ❑ Zoning Status- P; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Re tion; CSM <br /> (°2.1 -1 5 .41/O e.p._ • . t64 Ai t W ( 53111 Vari e(# ) <br /> ..M PHONE CELL PHONE E-MAIL ADDRESS <br /> S aio- o 1151 G(O - ❑ Site Plan drawn to scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA* OR NAME %) <br /> ,A IVO, DNS ❑ Site Plan in ing location <br /> AGENT ADDRESS CONTRA. OR ADDRESS of well/ tic <br /> 2 1.12A-2010 DR-' <br /> (City,State,Zip) (City,Stated Zip) ❑ Setbacks <br /> W I 53513 <br /> PHONE PHONE ❑ Site Plan appr rom <br /> ( 6 r- c, c. applicab wnship. <br /> E-MAILADDRESS E-MAILADRESS <br /> ,�,�, ' ❑ Floor pl scale <br /> A • >l• • • <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.uane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: P P rty <br /> ❑ y1it) 2 frontage drawn to scale. <br /> NUMBER 0���•S3-O `dV'�P �'r ��I <br /> TOWNSHIP: SECTION: <br /> It 'OL L^o`1 2_57 v4: s t 1k ,03 ❑ DCIV @Wa rmltS <br /> ADDRESS:F,O (stat ounty,town) <br /> • 1 + 5 w v11 5 t>� 11� ❑ Sanitary rmits <br /> CSM: �� LOT `� SUBDIVISIWN BLOCK/LOT (pub•' ,private) <br /> O c/ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROD ESCRIPTION: Wily- <br /> 10 / <br /> D u n I) ��� i n �� !FA Z Wing District <br /> This project is a new buildi g or structure. <br /> Permitted Use? <br /> ❑This proje is an addition/alteration to an existing'building or structure. <br /> SANITARYSERVI E: PERMIT NUMBER: ❑ Rural ` e,c. <br /> EWER/ ^❑SEPTIC �— (ne 'existin+ <br /> HEIGHT IN FEET: /ICJ NUMBER CiF STORIES: (Not including basement) <br /> ❑ Wetlan *lain/ <br /> ( Sha rid (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garkges and above grade decks or porches) <br /> �� ❑ ErosionCon cr.,permit <br /> BASEMENT 1ST FLOOR: j TOTAL SQUARE FOOTAGE: 4, (slopes,-«.. <br /> lirtg/ a ss) <br /> 2ND FLOOR: 3RD FLOOR: 9i- C Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ . '♦ '+ - -00. $ and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E po ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes iMA 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# ) (le a blank if none) <br /> 6. Is a location survey required? (see reverse) Yes 0 pro ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes lUd No <br /> 1 O 0 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />