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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT,to Web-App# <br /> PROPERTY OWNER'.INFORMATION CUSTOMER TO PROVIDE <br /> OWN NAME <br /> e LA t1 t �� /�'P ❑ Zoning Status;CUP; <br /> OWN RADDRESS (Number,Street Ciry,scare,zip) n Deed Restriction;CSM <br /> 2.4 13 i CX 9{� ICU 01 itk _ �'�'�o,GKt3Cii u)i.c Variance(# ) <br /> HOME PHONE CELL RHONE E-MAIL ADDRESS C� y <br /> 668--- 26757- -I'1 67 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes imenstong <br /> AGENT NAME CONTRACTOR NAME <br /> De v11.1.i, S 1 A /ey ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR AJçeJ EESS of well/septic <br /> Setbacks <br /> (City,State,Zip) (Ci Z �/ <br /> PHONE PONE ❑ Site Plan approval from <br /> PHONE <br /> Lt ) a �-6 GI/ / applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> `'Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.danewi.usl) f ti property <br /> vaon o <br /> Elevation PARENT = CURRENT ZONING: ACREAGE: P P rty <br /> NUM ER • r tp Q '/��1�► frontage drawn to scale. <br /> TOWNSHIP: SEC ION: <br /> / 1/: 1/41/4: ❑ Driveway permits <br /> ADDR / ` (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIOf�: <br /> "st. f7 -� <br /> DD �Qr- (-r) VD •SCI n ❑ Zoning District <br /> ❑This project is a new building or structure. Irt11 (Rdo+ ❑ Permitted Use? <br /> erThis project is an addition/alteration to an existing building or structure. °c#..0 . <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (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: <br /> ❑ ErosionControl permit <br /> .jam / q/5 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> I - filling/access) <br /> 2ND FLOOR: D FLOOR: ^ i / 9 5. <br /> � ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► ♦ ♦ ♦ -+ l7O 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 �I N�o Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Li !'J Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 6Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? as ❑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 io ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes aI <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0. -► -► <br /> 545-112(4/08) <br />