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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 /> v.. ❑Zoning Status; CUP; <br /> OWNER A DDRESS (Num reet,City,St te,Zip) <br /> 7-7� Nadi- � L G,,--1 n r e Deed Restriction;CSM <br /> Variance(# <br /> HOME CELL E-MAIL DRESS <br /> 737 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME '',,�� nq� <br /> dear-VI e✓ &A., .(OV .5 9-- 14 ,A 1 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ,t7 S lam-. PA <br /> (City,State,Zip) (CI ity,St ,Zip) c.) ❑Setbacks <br /> N�-moo— tNZ 71‘PHONE <br /> rz;:e 1 ❑Site Plan approval from <br /> , ./..e%---TFCIO applicable township. <br /> E-MAIL ADDRESS E-^'fIL ADDRESS <br /> (ex c-v';w,4).. a -. • • • .,. - ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONIN ACREAGE: <br /> ❑PARCEL �/� frontage drawn to scale. <br /> NUMBER all I-,;-71114 a.\,\ ~1 • .mss' <br /> TOWNSHIP: (� SECTIO <br /> 1X1 1/a: _6E '/1/: IQ' U Driveway permits <br /> ADDRESS: <br /> O r � '-`–� (state,county,town) <br /> 6-7-C" <br /> �� Pa 6t-le 3u,,Pccaci .l 3357,5 <br /> CSM: LOT ...ION BLOCIVLOr ❑Sanitary permits <br /> �� `f� i (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 3 W.---�cC)0 Jeck ❑ Zoning District <br /> OThis 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 /> FAT: IX6EPTIC (new/existing) <br /> HEIGHT IN FEET: ' 3 3 , ��1 NUMBER OF STORI1S: (Not including basement) <br /> f ❑ 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: t ST FLOOR: <br /> ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: t72'U M <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location Survey <br /> (Please round to nearest dollar) "♦ '∎ 'D. ♦ ♦ , <br /> $ 3l Qd� and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes a'Jo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ► , o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 75 o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes Elislo <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) DYes [ No Don't know <br /> 7. Is this to correct a violation? ❑Yes gNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 taioa> (Continue on Back) -+ -► -► <br />