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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 /> 5.-tve + (_t & 1& (4.0 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) P.0 - $6y_ 32- Deed Restriction;CSM <br /> OCecF'c t a/ 1AJ. 'S-7i'5 4 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 0 - (5-o'(9 (/`d& PSt (1'4 eer1/4.(1 ce .new 1; Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO TRACT• • E <br /> • a fa J Site Plan including location <br /> AGENT ADDRESS CONT', TOR ADD S of well/septic <br /> %o,o , • I . <br /> (City,State,Zip) (City,State,Zi. _ 1/4,.1-- Setbacks <br /> PHONE PHONE 3" "st i Site Plan approval from <br /> i_ gel; - — a 3 SS U applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS � ....7(6 C , <br /> 0CCCn!!lw���� loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usi) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Qtr( ❑ Elevation of property <br /> ❑ PARCEL 7 acre s frontage drawn to scale. <br /> ' <br /> NUMBER •7l -—3/4-806 3- 3 <br /> TOWNSHIP: Oef v(/�vi-/) t SECTION: <br /> 3 1 1/4: n/r iniA: S 6 Driveway permits <br /> (state,county,t <br /> ADDRESS: ty own) <br /> iSanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> D <br /> (public,private) <br /> A • <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: n <br /> Ad.A.4 r N+.GI/LC ❑ 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: J Rural Address <br /> ❑SEWER NTSEPTIC )7 S / lV f 1 P„ (new/existing) <br /> HEI HT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> •Z 7 . j ❑ Wetland/Floodplain/ <br /> �� �'11-e �� Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: %1FLOOR: ErosionControl permit <br /> _] f aV St 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> ]� t U�J filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED 14 A (,12 O 2/ Li Review Location Survey <br /> CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ ♦ "♦ "� ♦ "*. $ ?j 006 and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 4 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ,®No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 4Yes ❑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# ) (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? ❑Yes ,QNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► —i —► <br />