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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NW J, <br /> l'060-17' <br /> %'um ' L-�, 'e— ❑ Zoning Status;CUP; <br /> OWNER RUS (Number,street city, ,Zip) ,,// //����-� ? Deed Restriction;CSM <br /> l 7 b-g 6 Qt( v o' CAA) �/dcJy1 �l/� �7 � Variance(# ) <br /> H• E PHONE CELL PHONE E-MAIL•'DRESS . <br /> %12 d f JOOd is' "rGlG .040 i:,&d1A/' �❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <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: CURRENT ZONINe. ACR E: ❑ Elevation of property <br /> ❑ PARCEL v 6 l l.-32i-r � f 3>' frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: / SECTION: iwb3 <br /> 1"/-245-f4 $1,(6 -S 3 c2 %: ,,E-- 14%: �/t 4/ ❑ Driveway permits <br /> ADDRESS: > (state,county,town) <br /> T hg2-0•61i htv r'u' l✓ ❑ Sanitary permits <br /> CSM: _ /j w�f LOT/ /) SUBDIVISION BLOCK/LOT <br /> .�"/Y'7� !/�fJn (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: J_ q <br /> 19-hi\ <br /> Gh� a✓ /Q, e D 'f -. 0 ❑ Zoning District <br /> . `�'fhis project is a new building or structure. ❑ Permitted Use? <br /> Li This project is an addition/alteration to an existing building or structure. <br /> SANITARY SER�VIICE: PERMIT NUMBER: ❑ Rural Address <br /> LEI SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> ❑ Wettand/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: r-, <br /> ErosionControl permit <br /> • 7 Z 4 TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: '7 filling/access) <br /> `� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ A@ and available options. <br /> (Please round to nearest dollar) �P 50c)0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a-No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [3-Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Flo <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 Q No L7 Don't know <br /> 7. Is this to correct a violation? ❑Yes ®TIo <br /> i-7-cz)"7- OSg2 — Ct-i-wc�= n-t AtrcH OE 71-rE <br /> APPLICATION MUST BE SIGNED <br /> Re--42 i FUti'F. (Continue on Back) —► —► —► <br /> 545-112(4/08) <br /> tOLi " <br /> r <br />