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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME, n <br /> \L J ` `'�-' t1 ❑Zoning Status;CUP; <br /> OWNER A ESS (Num•er,Street,City,State,Zip) Deed Deed Restriction;CSM <br /> `�` 5 \ ` CC , ■A -' 35�ct Variance(# ) <br /> HOME PHONE CELL 'HONE E-MAIL ADDRESS <br /> •!l: sgger 3%11 ' s 1 •"' ) I,. v___•; , \ ‘..•M ❑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/) <br /> PARENT PARCEL NUMBER: ZO CURRENT ZONING: 'CREAGE: ❑Elevation of property <br /> ❑PARCEL Ol9AQ-?)l,k �p`1,p-cl Per, k -'lc frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ' 1(\ '/4: '/41A: ❑Driveway permits <br /> ADDRESS: L,,`,. G (state,county,town) <br /> \ 5 -%-�`'∎ L 6 1 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> .---- .pp `�i/Y■ `-k `4 y ' `" ❑ Zoning District <br /> ❑This 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 FIEPTIC (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) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 1. ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ $ .-7. R w and available options. <br /> (Please round to nearest dollar) `�W <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 of flhodplain 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? Dies Elo <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) ❑Yes Elo ❑Don't know <br /> 7. Is this to correct a violation? EYes alo <br /> 1v <br /> .. - APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► <br /> 545-112(4/08) <br />