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t <br /> 4so co <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 20'3'E9-:C- S 1fc1M1'E.N'.o' kC.Z ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> "g Goyaemir-‘e.\ D • , Woo'DS, mt... c,00,- 1 Variance(# ) <br /> HOM HONE CELL PHONE E-MAIL ADDRESS <br /> l Z( T E z e,..., • S C., ATT/ <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> I-A o'z A 4i SAMr`S ►--lE'(E0.-- LI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 400 LA ice_ S tAoie VIZ . <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Et�U-r t(Toi3t („) l 5353 el <br /> PHONE PHONE LI Site Plan approval from <br /> (P°8 6,34 • 3 Z 1 5 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL CS12' 'Z.S4•ZoSq,-9 - frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Q�.3 o Z S 1/4: SC. +/4+/,:'1�I vrJ LI Driveway permits <br /> ADDRESS: (state,county,town) <br /> "3y Co LA V-e- ).-409-.F... iJR.\\It. <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> S, , t4aoP1 eDeaco►a"x°C��an (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ea-R.vA—C%►-4( NovSe. tt ■(-c,,6%s0�y G LI Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> 1JThis project is an addition/alteration to an existing building or structure. . <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> "hlJ SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: 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: <br /> ❑ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: ,j, (Slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 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? 1O,Yes ❑No ❑Don't know <br /> \ <br /> 2. Is there a wetland or floodplain on or near the property? 'CJ Yes LI No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'Nfii 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# ) ((l leave blank if none) <br /> 6. Is a location survey required? (see reverse) .N41 Yes Yes ❑No LI Don't know <br /> 7. Is this to correct a violation? LI Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► <br />