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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 /> STe'e A A. S ei Le fL ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> g9S Tity�.oK ReAO� SAJK airy, Wi S3S83 Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Lob 1•43'49L Se;I 4 a.1 e_hor vs.na l` ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Saes AS Or/Nett, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of wellseptic <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 ZONING' ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 0colog f-193-9800.0 e.14 -i 3, 3S frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ❑ Driveway gaf+-'/ 19 '/a: Sv.l '/%: SE ypermits <br /> ADDRESS: (state,county,town) <br /> 4.8gS TAYc.oA. QoA01 SA-4K Ctrl ki S3S83 <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> /o9 0,Z L,,,�-- 3 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Dame—to' 0 G re .A4 ❑ Zoning District <br /> . This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> Cl SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2-o ❑ 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) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR'. <br /> loo O j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> 64.0 Z� 2 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ <br /> $ <br /> o o and available options. <br /> (Please round to nearest dollar) �V 1.0 OO O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1.No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2[No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? gYes ❑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 tSNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ZNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 larval (Continue on Back) -+ -► <br />