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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 7NAVE <br /> 64\ ( t( 'C - - ❑ Zoning Status;CUP; <br /> OwNERADDRESS <br /> ( Slree,city.S tete.zP> ' l 5 .� Deed Restriction;CSM <br /> (Q 3� Ww 4 l 9 , f sr <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> \ CONTRACTOR NAME <br /> 0 /- + i\�a 1-' ❑ Site Plan including location <br /> • <br /> AGENT ADDRESS CONTRACTOR ADDRESS • of welUseptic <br /> (City.State,Zip) (City.State.Tip) ❑ Setbacks <br /> PHONE 1\/‘-- __ __ PHONE CI 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) CI Elevation of PNREIIT PARCEL NU CURRENTZOI*G A property <br /> ❑ DER A -1 4 frontage drawn to scale. <br /> TOYC�N : SECTIf <br /> 0 O I( '(\, 0((1 1(-i4-- %/4: 1•1 1/41/4: i ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> . '91J2 9 Mae. 0-03\i 19 _--vre &1' k)( 5 3 S ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 0 tr.p=-1 to L6Ir 1 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO CT DErS�Cc IPTION: f' _ <br /> \r �1 \-i i- 0f TO 6.i1 Q t'u (3-Qresr l skin - ❑ Zoning District <br /> . ❑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 induding basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> El ErOSionCOntrol permit <br /> BASEMENT 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> fining/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST $@ and available options. <br /> (Please round to nearest dollar) ♦ -�► -I. -o. -, ♦ $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑Don't know <br /> 2. Is there a wetland or floodpiain on or near the property? ❑ No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 6,ar Yes ❑ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 4 ryO <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank' ) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes di <br /> o <br /> APPUCATION MUST BE SIGNED <br /> 545-112(arve) (Continue on Back) -1 ♦ -► <br />