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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 /> / 1 f C 4- yn-f A ic, ail iced" ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Numm ,City, tate,Zip) Deed Restriction; CSM <br /> `4 qv� l Git-)7�iCi.nS Xain. Variance(# ) <br /> HOME PHONE CELL PHON • Q� E-MAIL ADDRESS <br /> /). —3 ?— X # ad(e c$ <L %" C.A0, n � ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACCJORR NAME <br /> /2 jyj 4-i-Orel,ei C,ffl/✓!,1- Pozyt4 IsLc--- ❑Site Plan including location <br /> AGENT ADDRES CONTRACT R ADDRESS of well/septic <br /> �S?o /..era c gie./z ❑ <br /> (City,State,Zip (City,State Zip) rrss Setbacks <br /> SUn p /h,�f ail..c3 v <br /> PHONE PHO ❑Site Plan approval from <br /> ��✓.76p2j.) applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 1 j ,C+6 ,a4.L6,1-y ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PUMBER: CURRENT ZO ING: ACREAG <br /> ❑PARCEL o5r PARCEL 48D?-31 v-01).23-o �_1 A, I l frontage drawn to scale.t.NUMBER 10 ` f <br /> TOWNSHIP: SECTION: <br /> r' eld■ 31 1/4: /V&-' '/4'/4: S ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS:/ / to <br /> '"� gD /9' 11 �U K ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> i' leLd <br /> PROPOSED PROJECT INFORMATION . REVIEW <br /> PROJECT DESCRIPTION "'T <br /> /L 1,,/ P U Zoning District <br /> . ,This project is a new building or structure. U Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER 0 Rural Address <br /> EWER rEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> �. U UVetiandt ktodplain/ <br /> AREA TO NEAREST SQUARE FOOT: ShoCeiandIattact-tnertt) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: © ECC}SitC0ltlldl(3 d <br /> TOTAL SQUARE FOOTAGE: + (siopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: (r filling/access) <br /> Cd Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: � ._--- and available options. <br /> (Please round to nearest dollar) -► "� ♦ ♦ ♦ ♦ 8s (f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 111No ['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? ❑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 Olo ❑Don't know <br /> 7. Is this to correct a violation? :Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(4/08) <br />