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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS•NAME <br /> 12 oning Status;CUP; <br /> OWNER ADDRESS (Number,Street City,State,Z' <br /> 297 64ti ) 1)ri wt, 77 ! *hi WS S3 sey Variance Restriction;CSM ) <br /> HOME PHONE CELL PHONE E-MAIL AD RESS <br /> Geg-2/7 SSsT *oil_ aloe k - 4W' Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME w E <br /> [Site Plan including location T 1c" <br /> AGENT ADDRESS CONT'• TO• •'DRESS Of ell/septic <br /> (City,State,Zip) (City,State.Zip) [ ketbackrD NEM 5 . Q S <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: CURREN ZONING: ACREAGE: [ levation of property <br /> El <br /> NUMBER e4ir—?1,-8G9i—o C--/ „,1ci ] frontage drawn to scale. <br /> TO IP: SECTION: <br /> re5,.. d J�p`1 .S ® p,.• [Driveway permits <br /> ADDR SS: (state,court ,town <br /> CSM: / LOIe n n O SUBDIVISION BLOCK/LOT <br /> permits <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DEb c X10 i-1,11 6.411--Ian <br /> ❑Zoning District <br /> . ,rThis project is a new building or structure. 'Permitted Use? <br /> QThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: liRural • ••l- <br /> EWER OEPTIC )1--.C O I r_-nc)13 (new -xistl <br /> HEIGHT IN FEET: 1 NUMBER OF STORIES: (Not including basement) weUand/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 1 <br /> BASEMENT: 1 ST F B� ErosionControl permit ∎c-i <br /> l5 0 1 TOTAL SQUARE FOOTAGE: l (slopes,disturbance, J6' <br /> 2ND FLOOR: 3RD FLOOR: (� <br /> ynaccess) ��GQ <br /> \ J O Review Location Survey r S= <br /> ESTIMATED CONSTRUCTION COST: Q 0 and available pptt' ttS. <br /> (Please round to nearest dollar) 4" _ p <br /> o�J \ _ — � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves ❑No ODon't knoJj <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? Dies QNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EVes ONo <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) Elves fNo ['Don't know <br /> 7. Is this to correct a violation? EVes FNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) _ _ _ <br /> 545-112(4/08) <br />