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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 /> Ccek 1S I— `" Lc Ada Zoning Status; CUP; <br /> OWNER ADDRESS (NumbaiaStreet,City,State,Zip) eed Restriction; CSM <br /> 1 i .c.vnn Ac Q l C�-4- �1 w L s salS riance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 9,003- 61' 4I4 ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION :nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE Site Plan approval from <br /> pplicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Cloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONI ACREAGE: p p y <br /> ❑ <br /> NUMBER ER C355S• ClofS • y'o�al(3 ,— / . rj frontage drawn to scale. <br /> TOWNSHIP: L SECTION: hit,/—y.C�c�\C.si l ,/4: S ,E Yoh: / /„ rvwy permits <br /> ADDRESS: Y state,county,town) <br /> TAO ?eq./ E- G c ask ' S3e-A 3 ❑Ienitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT / <br /> ublic,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRIVECT DESCRIPTION: <br /> CZ•C.-9:1/4 c 0.ACkAj h Zoning District <br /> ❑This project is a new building or structure. ,fermitted Use? <br /> .This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: .� PERMIT NUMBER: ural Address <br /> ❑SEWER XI/,E'TIC ', (ne <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Wetland/F dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shor nd (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> fOSIOnCOntrOl permit <br /> 1.4 (1 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: �! filling/access) <br /> ' CO Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► -► $ nd 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 k No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? '®Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No 7, <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 A.No NtDon't know <br /> 7. Is this to correct a violation? ❑Yes 11 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />