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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> tiro 4 l tC O/ &/) <br /> ❑ Zoning Status; CUP; <br /> OWN R ADDRESS (Number,Street,City,State,Zip) <br /> ?fir€ i A�� ) 7-re ( Variance Restriction; CSM <br /> `C Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR SS <br /> •b237-go(c S- 332- (‘,13---/ ©H - S. k ' fe4S. r - 41`/ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 14 A 1/04- U 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-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL ©�/� ( ���7-� ,' Vet frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> Ill 12-ti C) 30 .1/4: A)t: 1/41/4: S r ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> tD—Acifi l.la:TAN) —III ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> 17 SCOTT i tt HFt tI(yvi0S <br /> PROPOSED,PRO,IECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> l 2! 1('O' l —O t JF G( St =, ❑ Zoning District <br /> . <br /> This project is a new building or structure. P d <br /> p 1 g ❑ Permitted Use? <br /> U This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER A SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 12i 1 ❑ 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 /> BASEMENT: 1ST FLOOR: 1-1 ErosionControl permit <br /> 14— /2 2_ ,, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> filling/access) , <br /> 2ND FLOOR: 3RD FLOOR: / <br /> )01+ k)/4- D (qZ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ///' and available options. <br /> (Please round to nearest dollar) -0 —0 ♦ ♦ ♦ -0 $ 7l CEND <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes �,p.No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes iL�l 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 No <br /> No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal it ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes LNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -+ <br /> 545-112(4/081 <br />