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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE.ablAME <br /> I 4-10H 3/t QFE V# iv '3L3 **- ['Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,St�aty Zip) _ Deed Restriction;CSM <br /> -z�C 43E-e-K .1 c31 /"/ -oc1)l 1, LUX .5371/ Variance(# ) <br /> HOME PHONE CELL PHONE 0 E-MAIL ADDRESS <br /> - s :y 9 1 G':. 4 1139 ! l'ACr-ti 11364)i)1 CIIN a' . t‘+ D Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> U 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 /> ID Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> Elevation of property <br /> PARCEL JI I- JJ�� �7 frontage drawn to scale. <br /> NUMBER �Zg1 O�t�E�f Qa1 '2+R- i O. 2.05 <br /> TOWNSHIP: SECTION: I O(D 1,1 10 E- <br /> '/1h: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> )'°LQ �c�►� $ \D l Sam S;,7 1 1 <br /> CSM: LOT SUBDIVISII N BLOCK/LOT ❑Sanitary permits <br /> S f 5 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> IgIThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <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: I—, ErosionCOntrol permit <br /> �n TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD F'OOR: <br /> Q filling/access) <br /> VO ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -i ♦ _, $@ and available options. <br /> (Please round to nearest dollar) $ 600 co <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Res QNo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes no ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes ao <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) QYes alo ['Don't know <br /> 7. Is this to correct a violation? ®Yes JVo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► -► -► <br />