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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 /> ` `e`-C ^A.. y 1�/ � Zoning Status; CUP; <br /> OWNER ADDRESS (Nu ber,Street,City,State,Zp) <br /> 6 1-7 f �'1( d, o, Deed Restriction; CSM <br /> 5cc"ffEE, � c y � '�' �� Variance(# ) <br /> HOME P E LL PHONE E-MAIL ADDRESS <br /> 60 • Lt 3'73 ?751 `;,,,_, 6 re lLeie.: 4 "N. J (0 ❑Site Plan drawn to scale <br /> AGENT:INFORMATION, 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-MAILADDRESS • <br /> ❑Floor plans to scale <br /> PR OPERTY/LOCATION INFORMATION (http://accessdane eo.dane wri usn., ,; _.: :., ❑Elevation of property <br /> PARENT PARCEL NUMBER:— CURRENT ZONING: ACREAGE: . <br /> ❑PARCEL ER 0 () I I -I - 6 U� , -, /�{_ , 70 frontage drawn to scale. <br /> • TOWNSHIP: SECTION: <br /> its 4 ., ' , /,/4: ❑Driveway permits <br /> 'ADDRESS: ////Gj�(,n55 /4 (state, county,town) <br /> 2. 6 77 58/,‘,.? N. it c(r <br /> Ili Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 5 /,,y �� (public,private) <br /> PROPOSED PROJECT INFORMATION - W TAFF'REVIE <br /> PROJECT DESCRIPTION: ar ti <br /> 6 14,'4 n Co or? =0 Zoning Dlsstnct l <br /> El This project is a new building or structure. F 4r ,:-: t k . ` r k, <br /> _� Permitted U.se? <br /> This project is an addition/alteration to an existing building or structure. - 5, <br /> f <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address ti -i ° <br /> EWER [EPTIC `(new/existing) <br /> HEIGHT IN FEET / tr NUMBER OF STORIES: (Not including basement) <br /> 7 6 <br /> L.117.,Wetland/F000dplain/ <br /> ;ter Shoreland`:(attachment) <br /> AREA TO NEAREST SQUARE FOOT , 4 <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR _ EfOS}OnCO OIf)lit' <br /> p 4, TOTAL SQUARE FOOTAGE + - slopes ai tu�rbance <br /> 1' s fiilitrlagccess <br /> 2ND FLOOR 3RD FLOOR: , j. ,i P{ <br /> _ 7LReview ocatlbrj Survey <br /> ESTIMATED CONSTRUCTION COST: QQ�� and available o�itions� <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ �p 2 ��i� _. a,; . Fg 4 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1211\10 ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes E o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes JNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes ❑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 jlo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► —► <br /> 545-112(4/09) <br />