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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NAME <br /> SWL SE �ivy L- 1 1 LC-' n Zoning Status; CUP; <br /> OWNER ADDRESS (N er,Street.City,State,Zip) 1 W4 �,��3 Deed Restriction; CSM <br /> 1?�° 1A-K t }✓, Variance(# ) <br /> •M PHON CELL PHONE E-MAIL ADDRESS <br /> .ret.� 0 o ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME -� CONTRACTOR NAME <br /> ( ) ( t1/3 n Site Plan including location <br /> A NT ADDRES ! CONTRACTOR ADDRESS of well/septic <br /> (oIaI oft/341 <br /> (City,State, (City,State,Zip) ❑ Setbacks <br /> }i/t �(1)31 t )i 5 3 7 I <br /> P N PHONE n Site Plan approval from 7 - - -71(� <br /> applicable township. <br /> E- AILADDRE E-MAIL ADDRESS <br /> A •Ve' • dmlS _,�j4��.`: ns-420 n 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 /> EPARCEL /5�, ,361/1:29),. frontage drawn to scale. <br /> NUMBER C/LCJ-� (�(�1 <br /> TOtaISHIP: SECTION: <br /> l et f 0 f- r }�«p A 35-- '/4: 5 1//1/: c L(.1 ❑ Driveway permits <br /> ADORES (state,county,town) <br /> C �l S L /"`T31 '" 55'71 n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: G,(,1/A �_ ^ 16 d <br /> ❑ Zoning District <br /> ❑T is 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 /> EWER rEPTIC (new/existing) <br /> HEIGHT IN FEET: I NUMBER OF STORIES (Not including basement) <br /> / <br /> ❑ 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 /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> f ©0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --• and available options. <br /> (Please round to nearest dollar) ♦ ♦ -► -r --• Q <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? nYes [Yr\lo f Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeslo nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? IYes rifio <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes 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? EYes %o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -+ -► <br /> 545-112(4/08) <br />