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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME X //-/ -?' )7//i /
<br /> G �� G4 C__ ❑ Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State, ) S3.)Zi Deed Restriction; CSM
<br /> �l/9/3 3 ,.�—e rr� e Z.----.--€,) Variance(# )
<br /> HOME PHONE CELL PHONE E- AIL ADDRESS e—C)-n 6r/� t-'v�
<br /> Gc)$, 7/ Z —ZZ. Z yobfu7`r-o ,•r..Ps/,,-r,uvSet, ,0 Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAM CONTRACTOR NAME
<br /> �/�.1/4�y s,T(..." »>, 4 77 ' U ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> 7 7 4,43�, .P/ fly 1.-f -9%?3 ,iX-.e i--e,e,P.2-c:Lz
<br /> (City,State,Zip) (City,State,Zip)i ❑ Setbacks
<br /> PHONE PHONE/ ❑ Site Plan approval from
<br /> 6- • V Z 3- Z ?vv ‘ Ug.. ,./2 _2 Zr Z applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDR SS
<br /> ro f orv/,, ,_ //),,,,..)6. 5E-.1 Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Li Elevation of property
<br /> ❑ PARCEL 06/Z ,c7Z cV3o•v Z�Za0 go y..)--7. frontage drawn to scale.
<br /> NUMBER /
<br /> TOWNSHI : SECTION:
<br /> Ci/sue/ '/,: 1/41/4. ❑ Driveway permits
<br /> (state,county,town)
<br /> ADDRESS:
<br /> 2 , "rp� `!� ��
<br /> J / —�� CI Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION ,STAFF REviEyy
<br /> PROJECT DESCRIPTION: '
<br /> w A.\V /-/'Y1. ❑ Zoning[ I nct
<br /> ❑This project is a new building or structure. (J Permitt Use ` s t.
<br /> ❑This project is an addition/alteration to an existing building or structure. r,1
<br /> SANITARY SERVICE: PERMIT NUMBER:
<br /> ❑'Rural Address =, . : "
<br /> ❑SEWER ❑SEPTIC (new/0(101ng) ' ,v
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> ❑ Wetland/Ftoodplain/
<br /> S.horeland (attachment)Aw '
<br /> AREA TO NEAREST SQUARE FOOT: ,;
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches)
<br /> BASEMENT: 1 ST FLOOR: ❑ [ rOSiOnCvnttiiii Hilt ,`�
<br /> 4 TOTAL SQUARE FOOTAGE: 4, �°(sl.pes;disturbance, ,„ 9
<br /> filling/access)
<br /> 2ND FLOOR: 3RD FLOOR: �(_
<br /> r '"� tC.IC 0 Review Location Survey '
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ O`1 C/ C\ 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? Cl Yes....1A'tQ'o ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes --till() ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? Yes ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ,...-des ❑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 --a1V CI Don't know
<br /> 7. Is this to correct a violation? ❑Yes No
<br /> 6 APPLICATION MUST BE SIGNED
<br /> (Continue on Back) —► —►
<br /> 545-112(4/08)
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