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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ei4 r' 4 IQJ$/ \I <br /> V — n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Z(00 Sc4+q-DC2 12.cj cZ'rfibQ- 611--12-1 wll S 3S21 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (oo y-0735-(opt/2 k ILHA,[XXMSc.ow /1 ��. ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS 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: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER Of Ski ll-344--ciBlo`0 V-1{- 2. 4.050 <br /> TOWNSHIP: SECTION: <br /> CkYrrNae GILIS tre, I4. %IA: ❑ Driveway permits <br /> ADDRESS: (state, county, town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> R 12– St-Fes) Zoning District <br /> MThis project is a new building or structure. J Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: LJ Rural Address <br /> FIEWER E)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> F Z 1 J 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: ErosionControl permit <br /> 1 TOTAL SQUARE FOOTAGE: 1 (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 144 <br /> filling/access) <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ - ♦ ��� and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ['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'? Dyes ❑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 ❑No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ON <br /> APPLICATION MUST BE SIGNED <br /> 545112(4/08) <br /> (Continue on Back) -► ■ -► <br />