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3`1)—>c _ (Y-7S S —r _791 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App It <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 3-1)C K • 0 C>C H u i e h be/2 0) ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,SStreet,City,State,Zip) ^� Deed Restriction; CSM <br /> HOME PHONE ��// CELL PHONE 7' NO e-I gILADDR S Variance(# ) <br /> 608- '76 �7- 7 yo 0V • 3 3`/- 'Pit ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Li Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) -�-.` (City,State,Zip) ❑ Setbacks <br /> J <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER C.)--) U 4, r i "-/ S.:r`c' j--i I '- J` C) <br /> TOWNSHIP: SECTION: <br /> N)Q 1"r„o N'�' -�- I 14: S f 1/41/4: J L Li Driveway permits <br /> (state, county,town) <br /> ADDRESS: <br /> 5_ f� <br /> '1 ! 0 CST" Li Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: j <br /> 1 5 Tv it y 0.6)61 0,-") ) 1 > r- =.) ❑ Zoning District <br /> ❑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 S'" / (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I ❑ Wetland/Floodplain/ <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: <br /> ❑ ErosionControl permit <br /> 3 c/a ,j, TOTAL SQUARE FOOTAGE: ,l, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: -\--- (1)._ filling/access) <br /> ESTIMATED CONSTRUCTION COST: <br /> Li Review Location Survey <br /> (Please round to nearest dollar) <br /> ♦ ..+ _I. -► ♦ ♦ $ \n � and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Li Yes 0 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes fl No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 1*(es 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 Ci No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -* -0 <br />