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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 /> :: o t•i ti t-1 v'.. ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> (0Z' 7 PV RC U LL ( o p D Ofitt;:e,„,oit 4_51 c3 4 7% Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60$•r11-0611 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR <br /> (Me t 4g iN G, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRAC OR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> $OO - 23(.. - 7 310 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 /> Li NUMBER O Vo,oci28oC/O a - 3 Z 8 frontage drawn to scale. <br /> TOWNSHIP SECTION: <br /> .'E" ( O (X• 'A: ,U 10A 1/41/4: A)C: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> $to W►tc <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ste*14 to 4 ft LO ❑ Zoning District <br /> . 3g 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 /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I <br /> Z / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> '{S x`� , 4, TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ -I. ♦ O O O 0 and available options. <br /> ' <br /> (Please round to nearest dollar) S j 2 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? A Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Flo ❑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? Za Yes ❑No <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 1401 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes xi,No <br /> 7 4'6 f 2 APPLICATION MUST BE SIGNED <br />