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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE: •ME <br /> �7/�� A''- C,11l t 0, ❑ Zoning ;CUP; <br /> OWNER •1Ft!SS ((Number,Street,City,State,Zip) JJ '' 11 estriction;CSM <br /> c�( 81 (_ ncg_(( L✓1 V2_frOlita W I 5-3619 ariance(# ) <br /> HOME PHONE v`' CELL PROM•E E-MAIL ADDRESS <br /> 3 • , i I ( $ 3 i iit• 7 U • Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> �� - to Plan including location <br /> AGENT ADD ER SS Cl/ <br /> CONTRACTOR DDRESS fwell/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> ' <br /> PHONE PHONE ❑ Site Plan a from <br /> • able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL N BER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL <br /> UM EL 0570 ^�7 7Q/`� 8 :- -o f/ -I L2, 3 5 frontage drawn to scale. <br /> NUMBER (J / 7 tlJ�/" <br /> TOWNSHIP: SECTION: <br /> _4 1/4:44.11 '/4Ya: A Ldp ❑ DrlveW mits <br /> qQ:r i nr da ('e- <br /> ,county,town) <br /> 77 I i VU1 rid(J O r...__ n V c(DnC l 1:i Sanita mits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> o r jc private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> r) e to-f („e j r e, j 1/C) Vvoning District <br /> . This jroect is a new building or structure. LJ Permitted Use? <br /> P <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ' •' - s <br /> ❑SEWER &SEPTIC (ne existing) <br /> HEIGHT IN FEET: J t WI <br /> /( ( NUMBER OF STORIES: (Not including basement) ❑ tland/Flo <br /> f nd (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 /> 1 TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> i 0 filling/access) <br /> 2ND FLOOR: 3RD FLOOR: '' ll <br /> \ 10 0 ❑ Review Lo • n Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -► ♦ ,♦ �jo o v and I able options. <br /> (Please round to nearest dollar) i F V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes C.l' lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes l iNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? L'Yes ❑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 i none) <br /> 6. Is a location survey required? (see reverse) l'es No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Z1No <br /> r--� APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ♦ -► <br /> • <br /> 545-112(a�oei i —5� r <br />