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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 /> W <br /> OWNER i" •� Oki'G e v <br /> U Zoning Status;CUP; <br /> DDj $(Number,Sreel,cStata,Zip) c Deed Restriction;CSM <br /> // ,it G> O 5 0 1-u LJ ( �3.�75d Variance(# ) <br /> OME PHONE CELL PHONE E-MAIL ADDRESS <br /> OF . - ' ?2 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION f CONTRACTOR INFORMATION and includes dimensions <br /> AG NT NAME CONTRACTOR NAME <br /> �'t '�� Z. 'C I ❑ Site Plan including location <br /> AGENT ADDR S CONTRACTOR ADDRESS <br /> F6 C / fi G L 1 k of well/septic <br /> } t r-ef <br /> (City,State,Zip) {� (City,State,Zip) ❑ Setbacks <br /> ,C)it Q ti ///, W/` ; 3-f//7 J <br /> PHONEY PHONE <br /> (G 0y\ # <br /> 3$ -CZ./KY Site Plan approval from <br /> l / applicable township. <br /> E- •ILADDR SS E-MAIL ADDRESS <br /> C S C 4 e! C C L a f�e... v.c"�' ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wi.usi) <br /> PARENT Li PARCEL PARCELNUMBEI (/Z A s- „ CUyettE.ljZONIrG: ACREAGE: ❑ Elevation of property <br /> NUMBER /L` 1/- /ZO K ry frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> O 1- . 01N it, 1/: 54- 1/1/: SE ❑ Driveway permits <br /> (state,county,town) <br /> ss• /� / <br /> ` ' ti <br /> �// �4- r•e s�C. i. Ov- o,,` 1 J t . '7S 7S ❑ Sanitary permits <br /> CSM: LOT SIADIVISI0141 BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT DE ION: <br /> l oJ-•e- Ct r t1 ❑ Zoning District <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGH FjET NUMBER OF STORIES: (Not including basement) <br /> 6 I ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches <br /> BASEMENT: 1STF R. porches) ❑ ErosionControl permit <br /> / 66 51 r j TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> /96'0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► ♦ ♦ ♦ /�/ 0, and available options. <br /> (Please round to nearest dollar) $/H t� 2 0,d 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 6No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes allo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 43-Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Cl Yes atNo <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 1 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes W-No <br /> 47- ;^� APPLICATION MUST BE SIGNED <br /> /t/' (Continue on Back) - -o• ♦ <br /> ► - - <br /> 545-112(4/08) 50 <br /> 1457 <br />