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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> K Y <br /> PROPERTY OWNER?INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> DAJV 4,L_ ot c^ \ T ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 2 q-JZsz_ Q I Mt5�,--1 ; l.>t 53�R Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 224-(253 P12) --(02)2_,-/ — ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME n CONTRACTOR NAME <br /> tS-r�i UO�ST`t-°C-TtOts1 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> W1-0 Joni (1kip - ZY . <br /> (City,State,Zip) (City,State,Zip) -1 ❑ Setbacks <br /> ■AOkS>J i UI 5 3 -1 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 25 Z.—. i4DLR applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> -"eYLSa- Q c\-\,(4e`nSenconS-.}yoc.hon , nek ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> NARCEL bio I DD eZ(Q 119(40 R- 3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> •�DuNaJ '/a: 1/4i/a; ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 232 BE,rtrcAQ Sj 1 QAA DISo..) iUi 5L-i-II <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION • STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> -Da -rr ('o) 114 ( DtA )0 / 'D-�--- ❑ 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 /> ER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEE : NUMBER OF STORIES: (Not including basement) <br /> -� ` r ❑ Wetland/Floodplain/ <br /> P� 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 /> ❑ <br /> Li permit <br /> j, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 220 Z 2v ❑ Review Location Survey <br /> •ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ -r ♦ and available options. <br /> (Please round to nearest dollar) $ 5,00,fl <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 12rYes ❑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'? 'TYes Li No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes !WVo <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 PNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► - <br /> 545-112(4/08) <br />