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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 /> % �7-&-.A. ,c /4-714, `1-7/ Z----47,A-- ate. <br /> CI <br /> Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> r��� Deed Restriction; CSM <br /> �,, c 2° A a Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Zit - y/9i <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> /°�' c, 1P 4,e_ /i, 'c-,b/ev �.--a-, 54 c ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City, te,Zip) ❑ Setbacks <br /> G_�o-r'C"N ai t `1j Ko✓b , e'44 r3SZ?, .o-rr"P 6L�,LcVJd Z7- -5.--- IZ-•7 <br /> PHONE G v�l- �f0/ PHONE 4,67._L- ef�j i ❑ Site Plan approval from <br /> (,c0.9) Z z T - y (6-o eJ z z r - erjr0159 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> PARCEL O tiZfc�ra 9_}j g/-B!eS-G K `/ frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> c->"c5 A"/ 7 /a: 5 z /-1/4: (1, ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> l 2 6 7 c L.r- / e•-'/0 N - (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> A- --�. " v.67-1.).4., >✓ )4k a,r.o/,> ,.' c/4-- ❑ 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 /> 0 SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> , ' ❑ Wetland/Fksodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ <br /> BASEMENT: 1ST FLOOR: —` Erosion�' trCf(permit <br /> 2ND FLOOR: 3RD FLOORS 3 S 57-r- 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 5-3C S: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ' ' ♦ ���nc <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes '4No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes cl No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes IZI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 4No <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 ONo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 14 No <br /> , i <br /> S 0 APPLICATION MUST BE SIGNED <br /> `� oc) (Continue on Back) -► -► -∎ <br /> sas-ttz(4/08) ,u7 L), <br />