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, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 6ir6 b* / if/lG� ❑ Zoning Status; CUP; <br /> Ovv RADDRESS umber,Street,City,State,Zip) Deed Restriction; CSM <br /> i����/ 11 ,�dU9 � � ) 4evie,ecih '�? Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> l 3, 9y - IT rive - GENE /1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / /'r <br /> 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Tip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> f PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usl) <br /> PARENT PARCEL UMBER: CURRENT20NINC} ACREAGE: / Cl Elevation of property <br /> PARCEL <br /> UM EL o/e7ey 44' _� i'-9 �{ „, 7 �//��j frontage drawn to scale. <br /> NUMBER � 7 y , I Y /1 <br /> TOWNSHIP: SECTION: <br /> /4/41,P4 diZ / A--- 'h:Al W x/41/4:/ I Iv <br /> ❑ Driveway permits <br /> ADDRESS:/ (state,county,town) <br /> li-W lf/l1el� me° ,4' '7 /10444,i 4 / ,2 4/, ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJEV t 12f,.re iti 0 /4",,,� e +.30 ❑ 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 U SEPTIC (new/existing) <br /> HEIGHT IN FEET: i) NUMBER QF STORIES: (Not including basement) <br /> ,y /g, / ❑ 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: r--, ErosionControl permit <br /> 79 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR filling/access) <br /> 77 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ,x- t�6 G and available options. <br /> (Please round to nearest dollar) '♦ -+ -► ♦ ♦ "'. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes aKo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®1Go ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Et Yes CI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <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 ❑fro "Don't know <br /> 7. Is this to correct a violation? ❑Yes NO <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) • -i <br /> 545-112(4/08) <br />