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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> • CUSTOMER TO PROVIDE <br /> OWNER IslAIL-4, '. <br /> ACC/ Ta„(---1-loy D Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City State, ip) Deed Restriction;CSM <br /> _ I .,o9 81-filics- Wil'il Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 18 L22 - /7 I', - ...i 4_, Li Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ey Pi7 CI Site Plan including location <br /> AGENT ADDRESS CONTFtACT ADDR SS ' of well/septic <br /> ) hilo‘Arc Uitil <br /> (City,State,Zip) (CV„State,Zip) CI Setbacks <br /> St/Ai Te-iiViti i ull <br /> PHONE PHONE i CI Site Plan approval from <br /> i•T- A26---.610 81 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> CI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: CI Elevation of property <br /> Li PARCEL <br /> NUMBER 64 <br /> frontage drawn to scale. <br /> 540 cCmitty > ie7G-pC_ <br /> TOWNSHIP: SECTION: <br /> T11-t) 14: 1414: CI Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> Lof q ,.. cici Li Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> i -- C! (public,private) <br /> ;P ‘1' <br /> __),- A1 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: _ <br /> $1O4,/f flefry 1_11 &Ili_ CI Zoning District <br /> . A This project is a new building or structure. CI Permitted Use? <br /> CI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> 0 SEWER )(SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> CI 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 /> LI ErosionControl permit <br /> /2SEMENT: 1ST FLOOR: <br /> 4, <br /> (slopes,disturbance, <br /> TOTAL SQUARE FOOTAGE: 4 <br /> filling/access) <br /> 2ND FLOOR: /RD FLOOR: - <br />. /ESTIMATED CONSTRUCTIOdOST: / j Review Location Survey <br /> and available options. <br /> (Please round to nearest dollar) -0. -0. -0. -0. -10 -40 $2-23-rcip <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Li Yes freNo CI Don't know <br />, <br /> 2. Is there a wetland or floodplain on or near the property? CI Yes No Cl Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? gjYes CI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? CI Yes OW <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) Li Yes ki No CI Don't know <br /> 7. Is this to correct a violation? Li Yes 'No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 -■ -■ <br /> 545-112(4/08) <br />