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t''CJlen * SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> �r Id Derr ❑ Zoning Status;CUP; <br /> OWNER AD 1R/,E�ESSSS (Number,Street,City,�State,Zip) y Deed Restriction;CSM <br /> • <br /> HOME PHONE 5 C PHONE ' kW E-MAIL K ( Olurn�S \1 �25 Variance(# ________) <br /> or Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 3eSSIC,U E►rosso pm Cirosso Btmers uc, ❑ Site Plan including location <br /> AGENT ADDRE CONTRACTOR ADDRESS of well/septic <br /> OA Varad or Pi. 31_111 m ilex S+. <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> *rove N(t 5?)5g-1 YYl adtsm VC 531(A <br /> PHONE PHONE ❑ Site Plan approval from <br /> LP - 5� �l i2 QG [ c - 3i applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 'y tSp@ OW,C4On,l ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PAR EL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL <br /> • frontage drawn to scale. <br /> NUMBER i 0 ei - 6AJ-G4..b'0 f ■ - •5 <br /> TOWNSHIP: of SECTION: <br /> - <br /> 1 (7w n CSC r yorL 1 I._F ___ '/ :_5W___ ❑ Driveway permits <br /> ---�-- �'— (state,county,town) <br /> ADDRESS: <br /> 16y.ii s id • ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> laa B - N A At/41 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> doleX n ❑ Zoning District <br /> . litThis 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 /> ❑SEWER VSEPTIC (new/existing) <br /> HEIGHT IN FEET:0)3 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: 1--, ErosionControl permit <br /> (/y„5 1 TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> (955a <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ -► /41:1 and available options. <br /> (Please round to nearest dollar) , 000 <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 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? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes CiiNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) — —+ <br /> 545-112(4/08) <br />