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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME <br /> John W Herm ❑ Zoning District <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 2533 Lalor Road,Oregon,WI,53575 ❑ Permitted Use? <br /> PHONE E-MAIL ADDRESS <br /> 608226-9331 jwherm @wisc.edu <br /> ❑ Zoning Status;CUP; <br /> AGENT INFORMATION (CONTRACTOR INFORMATION Deed Restriction;CSM <br /> AGENT NAME CONTRACTOR NAME <br /> Variance(# <br /> {. ) <br /> 1G rJ 111 <br /> AGENT ADDRESS CONTRACTOR ADDRESS ❑ Site Plan drawn to scale <br /> �.�. . <br /> and includes dimensions <br /> (City,State,Zip) (City,State,Zip) <br /> ❑ Site Plan induding location <br /> PHONE PHONE <br /> —,'- r • of well/septic <br /> E-MAIL ADDRESS E-MAIL ADDRESS ❑ Setbacks <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Site Plan approval from <br /> PARENT PARCEL <br /> PARCEELNUMBER: ZONING: _ ACREAGE: <br /> NUM ER ac2 3/ooe-/K2 w-0 A -I E/Y 3B applicable township. <br /> TOWNSHIP: SECTION: <br /> 0(49 g /4: (h f ❑ Rural Address <br /> ' /�/ l�l/ '/.'/.: S (new/existing) <br /> ADDRESS: <br /> 2.133 Lf-L d E / c i2 eCo N, lx)-Z 5-3 5-75 ❑ Floor plans to scale <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ❑ Elevation of property <br /> PROPOSED PROJECT INFORMATION frontage drawn to scale. <br /> PROJECT DESCRIPTION: <br /> Teo-)k C NA,N ul.A < Lk.k.L t) R iv C-;- Driveway permits <br /> . CI This project is a new building or structure. X1 9 (state,county,town) <br /> IJ This project is an addition/alteration to an existing building or structure. <br /> ❑ Sanitary permits <br /> SANITARY SERVICE: PERMIT NUMBER: (public,private) <br /> ❑SEWER L}7 SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> I C' 1 ❑ 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 /> TOTAL SQUARE FOOTAGE: j (Slopes,disturbance, <br /> fillirtg/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> L ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 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? ttirYes ❑No ❑Don't know <br /> 2. There is a wetland or floodplain on or near the property? 3-Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project? g'Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ago <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? Yes ❑No ❑Don't know <br /> 7. Is this correcting a violation? ❑Yes C3 NO <br /> APPLICATION MUST BE SIGNED <br /> 545.112(1/08) t „ µ (Continue on Back) <br /> 6 7 X20 <br /> I-7 0 ,0) <br />