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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #_ziil - .A.3/79 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> J 'c Z_ G?..i— . ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> /..S-7 L) T7 Oc r 74-- r--. 1 1'i i.c/// t✓� -C-3 3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ass- iwy ,I9S- 7�/S - 22, -Ger-®�1-orr.„.-r, yip f ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I 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-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER (IS/-7-/9,38 ,..5—_.?_18" Co ` 4/<S'-y frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Al /e- r'�e„. 1 9 ' : J l./ %'A: mi..... ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> / 7 0 i r Cc-f-' D . +"tom' I 214 //,�5.�53 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (0'A LD .�-. (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> -H-Q c-Ccoc �cc.._i__ ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> LThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER laSEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> ❑ 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--, <br /> ErosionControl permit <br /> /O 7/ / O / j TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> /O? / �.-.) /3 L ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �s 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 Q No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes It No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 0 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 64 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 ®No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 4 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4. -► -i <br /> 545-112(4/08) <br />