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ZONING PERMIT APPLICATION ww.countyofdane.com SUPPLEMENT to Web-App # <br /> • w <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE h I, <br /> 41- 0 , (A) '( (t v . A tot:, <br /> WZoning Status; CUP; --3 <br /> OWNER ADDRESS umber,Street,City State,Zip) Deed Restriction;CS <br /> �t cJt/v r� , Yi16t) i> (--6) _ r77/ Y Variance(# ) <br /> HOME P *NE CELL P ONE E-MAIL ADDRESS O' <br /> d' o o� V—s 3 Z a3Y-i r-6 IDs`I(r-c�� @' C �-.-f'�', i✓P-(� j Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> XSite Plan including location A--- <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic'�n <br /> (City,State,Zip) (City,State,Zip) MSetbacks ! 'V, /1/2 <br /> PHONE PHONE Li 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 PARCE NUMBER: CURRENT 3�ONING: ARREA E: ❑ Elevation of property PARCEL <br /> ❑ NUMBER af( 0710-0�,� -4 j 4 I frontage drawn to scale. <br /> TOW SHIP: SECTION: <br /> \cc � �. G ✓�. '/4: '/n'/a: �J°�,(�' <br /> Driveway permits r/A_ <br /> ADDRESS:, ) state,county, <br /> 1 p� eci 1,{�I C 1---. ,Al C i irk") t 0 , , tv 5 S 7/ /[ Ai S permits /�1 <br /> CSM: LOT SUBDIVISION ' BLOCK/LOT f 1/ <br /> ubli private) l� Y <br /> PROPOSED PROJECT INFORMATION STAFF REVI <br /> PROJECT DESCRIPTION: <br /> i-Lc l C ` l '� ` .5 zY cc( e S(,�)J9 /O / • <br /> r r. Zoning District ...-3 <br /> . tiarThis project is a new building or structure. X Permitted Use? h � <br /> ii This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERV E: PERMIT NUMBER: Ogi Rural A•• == <br /> SEWER ❑SEPTIC (new 4P <br /> HEIGHT IN E : NUMBER OF STORIES: (Not including basement) J/14' <br /> l / 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 /> K <br /> BASEMENT: 1ST FLOOR: rosionControl permit A <br /> /ye , TOTAL SQUARE FOOTAGE: ,, SIO•i •• ••.-nce, <br /> 2ND FLOOR: 3RD FLOOR: ) I ,F ,"-`-'- Iny+ cess) ' <br /> �_`/ 1 ❑ Review Location Survey • <br /> ESTIMATED CONSTRUCTION COST: $ and available options. <br /> (Please round to nearest dollar) ♦ ♦ "� ♦ ♦ ♦ �P ,� . C <br /> s <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 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) le ve blank if none) <br /> 6. Is a location survey required? (se- -----""" y Yes DNo ❑Don't know <br /> 7. Is this to correct a violation?... ❑Yes i*lo <br /> 6 /I ©® APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ -g <br /> 545-112(4/08) <br />