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it • <br /> . ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN R NAME . \^'^ �]�] <br /> OWNER S dr, �`)�\ ,c1 ` V'1 \b 1 ( çcC,Q4 �Q Zoning <br /> S umber,Street,City,State,Zip) ❑ Zonln Status; CUP; <br /> �4 `'\ 7 r( C/r/ I Ti5)r Deed ce(triction; CSM ) <br /> yNE 1\ `� J Variance(# <br /> HOME PHONE CELL HONE E-MAIL ADDRESS III <br /> O.• • .. :�, 1. *a AN _ 0 • . '•.• • L. It. ,'_ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 'SctxrJQ Q b i,onctr ❑ 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.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER i\a(pg C'13d453 190O R14 - 2 3.04 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Tott OV 13Q,C '/4: '/4%4: ❑ Driveway permits <br /> ADDR�E,JS/S�: (�_ 1 (state, county,town) <br /> cat 0 3 Icd oetry J. ' \�0 vlsiary(rf Wfoc 331 ❑ Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 1� CceSSO v ■ 1Ct\Y--) ❑ 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 /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> r ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ,---. ErosionContr0l permit <br /> 1_1 j TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 11 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ '+ ♦ ♦ Q� � F� and available options. <br /> (Please round to nearest dollar) $ f S- U e) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes liNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No gl Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 11Yes ❑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# g9lo <br /> P 1 (p pp (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 0 No El Don't know <br /> 7. Is this to correct a violation? ❑Yes 'No <br /> ,g�Zone cgL4L-\ <br /> APPLICATION MUST BE SIGNED <br /> 112( � l',0 P (Continue on Back) -► -► -r <br /> 3 <br />