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''t . IO'iliti===1 <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER f ` <br /> --+-'il c` 11 V <br /> ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (N mber,Street,City,State,Zip) Deed Restriction; CSM <br /> hoc c+ i ',i She . Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL_ADDRESS . I <br /> ,/g- 22O-Zq, .e. kreviA010m3\n5-, m ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> A NAME CONT TORN �,f <br /> jev'unty /cci�i cd/ r5- f&jibei ❑ Site Plan including location <br /> AGENT ADDRESS/ C NTRACTOR ADDRESS of well/septic <br /> jay fA0e L IA( <br /> (City, ) (City,State,Zip) ❑ Setbacks <br /> i rk t'o ' t 1 th X3/6 Civte- <br /> PHONE / PHONE LI Site Plan approval from <br /> ‘09•d-.25-'?6 0 3,-,-< applicable township. <br /> E-MAIL A DRESS E-MAIL AD ESS <br /> 0 rc )c tier/114e Ile - - ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: C� CURREN ZO ING: ACREAGE: / LI Elevation of property <br /> ❑ UMBER ©g'C�._Z9-- r � 3 � r . v / frontage drawn to scale. <br /> TOWNSHIP: SECTION: p <br /> b ar )-c---- Y4: 1►4 W %4%4: S G ❑ Driveway permits <br /> ADDRESS: / (state,county,town) <br /> SL o7 T/2c2�-Sdn a ri., <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> CSC. r (public, private) <br /> • <br /> PROPOSED PROJECT INFORMATION *W REVIEW <br /> PROJECT DESCRIPTION: //1 /04./ <br /> a(l 1--- bV/ ❑ Zoning District <br /> . /TThis project is a new building or structu . <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> SEWER 121 SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Iii <br /> �.-- ❑ Wetland/FIoodplain/ <br /> I Shoreland (attachment) <br /> A TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including un inished area,attached garages and above grade decks or porches) ❑ Erosbnl onb permit <br /> BASEMENT: 1ST 11500 4, TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> I CU <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available options. <br /> (Please round to nearest dollar) -4. -4. -0. -► S t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Vi No LI 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? L'Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ØYes ❑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 6 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -♦ -► -► <br />