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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 /> id();//, 4/21 cD • 6.L(4 Ut 1z_, ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 Cp� �t,2, ,tt ea. E64Etz, c7,) (1.;Se, 53S34- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> bo; .- , x¢--4731; ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> L_] 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.wl.us/) <br /> PARENT PARCEL NUMBER: CU NT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL /15/rl_d'1 _�J(iyi_/_ IL-- r1 '1 F frontage drawn to scale. <br /> NUMBER VV d d Jd t(' �( O� ` <br /> TOWNSHIP. SECnTIO : 5v.) N ❑ Driveway permits <br /> I b i 0•'• '/4: '/4'/4: y P <br /> ADDRESS: (state,county,town) <br /> 5,8 8 E ba C2-f ctP} R. r 69 e 4 ct/t,) (x.'5 `. 5:3 3-3 4 ❑ Sanitary permits <br /> CSM: LOT BDIVISI N BLOCK/LOT <br /> OLLT 0T Ci8 x • -It&. U; 1/c e y1 Ib ; , n (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: A / / <br /> 4, A 2 A -'� x 00 =` eil ❑ honing Dis rict <br /> This project is a new building structure. <br /> ❑.Permitted Use? <br /> LI This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: L Rural Address <br /> XSEWER D SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> J� 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: I` <br /> filling/access) <br /> O 60 ❑ Review Location Survey. <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ -► and available options, <br /> (Please round to nearest dollar) $ / J, CO C) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,4-,/No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes !�d No A Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? AYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ANo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le a blank if none) <br /> c <br /> 6. Is a location survey required? (see reverse) Yes LI No l,al Don't know <br /> 7. Is this to correct a violation? ❑Yes 4 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />