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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> p\\1:51 on Se\c' SkD(0a .e LLB ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> no U.5 �1iaihrlay 5/ N Um r I Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ■-S i 14''100 Li Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> &,ene. as OvJne c `jQ1(`(1Q Qs Du ner CI Site Plan including location <br /> AGENT ADDRESS CONTR ACTOR 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 /> Li Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: / CURRENT ZONING: <br /> ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 0021 0612-2-z'1- 00i-o C-/" 0.4 L7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Atbi a rl i7 7 1/4: Se 1/41/4: sE ❑ Driveway permits <br /> ADDRESS: C7� L. (state,county,town) <br /> -1D u $. Ni ahwrat6 51 N Li Sanitary permits <br /> CSM: irtiatv�M LOY SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PiNiON eommucialC.onde <br /> PROPOSED PROJECT INFORMATION i4f4i0o <br /> STAFF <br /> PROJECT DESCRIPTION: <br /> V�0.k1 sign beino� added bu;tldin� In process :❑ zoning District <br /> . ❑This project is a new building or structure. 14 `AAnbt * ❑ pe mtt e ?� <br /> ❑This project is an addition/alteration to an existing building or structure. ,,�� <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> ❑ Rur°atAddr <br /> SEWER ❑SEPTIC 'anew/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �—"•• t <br /> Wetland/Fl dpiain! <br /> \OJri= 10' v 30'Lono, —wi!1 (lot be highermar% 50' -from gt 't.ndb S orela s (attachimt�ent) <br /> AREA TO NEAREST SQUARE FOOT: 4op 0, SIi0n y�lhenirc)tA n � & <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches : � <br /> BASEMENT: 1ST FLOOR: • jr ��t <br /> 4,, TOTAL SQUARE FOOTAGE. + ' 'I opes,disturbancE, - <br /> 2ND FLOOR: 3RD FLOOR: fl(IngiaCCess} <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ ♦ ♦ ♦ 2 � avatlaible 0* ns <br /> (Please round to nearest dollar) D3, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Li Yes LNo Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Li Yes ANo Li Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? G:Yes ❑No r� <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? AY9gx. No zoos() ?�� <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (IealvB blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 314No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes xi No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />