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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 /> C-CI( -r'`,1;C-7i.`. ❑Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM
<br /> ;,a)..`.)J{;:' Lk) i j `'{I ) _( ,.,,,c, 0-\.,,,, s. l 4'1`\(2` ", ---,✓ (-4,11 Variance(# )
<br /> HOME PHONE CELL PHONE E-MAI ADDRESS t
<br /> '4".(- e J "'' - `.x'rJ.s'e-s, a .F • ❑Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> `oaf".,,Y _ ❑Site Plan including location
<br /> AGENT ADDRESS �' CONTRACTOR ADDRESS of well/septic
<br /> ".i)-7,,,I (}y\t.>-, r,J=° u -
<br /> ),' K,j
<br /> (City,State,Zip) / (City,State,Zip) ❑Setbacks
<br /> al f'..i))°:�,"./'...1 .} ,.1,. - a _/i R..
<br /> PHONE PHONE - ❑Site Plan approval from
<br /> (,)?"--)F ) a??) _ ,,,,5:5 applicable township.
<br /> E-MAIL ADDRESS L oC d t..., r E-MAIL ADDRESS
<br /> r , El Floor plans to scale
<br /> c ,., "'C t: es ar"' .-„ ,per.
<br /> PROPERTY/LOCATION INFORMATION (http:(/accessdane.co.dane.wLus1) f ti property
<br /> o
<br /> Elevation ro
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y
<br /> ❑PARCEL : frontage drawn to scale.
<br /> NUMBER ','3,1 c-1 G 1' Y 3 ,r o =: C -- )- !
<br /> �• (:,
<br /> TOWNSHIP: SECTION:
<br /> • 1 2 I r? 1/11/4: 7 � ❑Driveway permits
<br /> _ t._,�.3i ) ( \ r- 4 `,„Sr;”-' C / /4: f = (state,county,town)
<br /> ADDRESS:
<br /> 3/C' (.),,, (:._)';')c. 1-4 t ■:u('_ ("\ti)-.)_ ❑Sanitary permits
<br /> CSM: LOT , SUBDIVISION BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> ❑ Zoning District
<br /> . ❑This 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 /> DEWER rEPTIC (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: f---1
<br /> ErosionControl permit
<br /> 4, TOTAL SQUARE FOOTAGE: ,`, (slopes,disturbance,
<br /> filling/access)
<br /> 2ND FLOOR 3RD FLOOR:
<br /> Cl Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ -4. -+ -. 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? ❑Yes ❑No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ['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 Oto
<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? Dees ❑No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) —► —► —►
<br /> 545-112(4/08)
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