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ZONING PERMIT APPLICATION www.countyofdane.com SDPPLEMENT to;vYeb App# ; <br /> :. : 'PROPERTY OWNER INFORMATION ' ':' ';; ` . .. . -;_ 3;" ,.ii` CUSTOMER TO PROVIDE <br /> OWNTA <br /> V1 ' c ,c/ /',/� <br /> S(4.11 I I Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,Ci,e, SS7e,Zp) i " `- Deed Restriction; CSM <br /> 5-5-5- L i? (Aar' YOU �d v Y".c2. 5 3 5 3 �/ <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6v, -dd'c/./P1 ' &J -'2- q 6 ei'4y ❑Site Plan drawn to scale <br /> AGENT.INFORMATION '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-MAILADDRESS . <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION`INFORMATION `(httpi//accessdane coda_ ne,Wi use a <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE. ❑Elevation of property <br /> ❑PARCEL + 5,i Z" z_'1 3_ /71o, 1 <br /> frontage drawn to scale. <br /> NUMBER 0 <br /> TOWNSHIP: , SECTION: <br /> �. %<: %4%<: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: L I 9q vv-1 - _ _ <br /> 5-5-5 ' ' " ` i 1 . 3 3} ?y <br /> ['Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> • <br /> PROPOSED PROJECT INFORMATION = - STAFF;REVIEW <br /> PROJECT DESCRIPTION: <br /> SSA Q Lf y <br /> fJ Zoning District , <br /> . ❑This project is a new building or structure. b Permitted Use? . <br /> ❑This project is an addition/alteration to an existing building or structure. - � �� } r <br /> ® Rural Address.�� <br /> SANITARY SERVICE: PERMIT NUMBER: , <br /> FIEWER EPTIC '6 *{new/existing) :J'- <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not inducting basement) <br /> . I ❑ Wetland/Floodplaip/ :- <br /> Shorelandr(attachment) <br /> AREA TO NEAREST SQUARE FOOT r ,; <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) 6- c F = <br /> ® ErOSIOfCOntrol permit' <br /> BASEMENT 1ST FLOOR: :+z xo- '-- <br /> + TOTAL SQUARE FOOTAGE: j -" lopes5dlsturbance <br /> r s filiing7accessPS <br /> 2ND FLOOR: 3RD FLOOR: r /, 1 k'z fi ,ss46G1. 7, _ter 4. a� Review.Location Survey <br /> ESTIMATED CONSTRUCTION COST: ¢and avalla"ale options <br /> (Please round to nearest dollar) "♦ --► --► --► --► ♦ 0o :_y,._Y�' , ;t�3 r=;\ <br /> ' 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IJo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Rflo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ 'es ❑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 Efvo ❑Don't know <br /> 7. Is this to correct a violation? [Yes aio <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -+ -► <br /> 545-112(4/08) <br />