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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 /> fie( K rG ozS H ''A ti G ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �'r�� Deed Restriction; CSM <br /> HOME b3 9 Fa CELL PH\ Ra E-MAIL ADDRESS c' 6 t 33 Z Variance(# ) <br /> I ^ 6-6,S In Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> rl k FceS 114 tic, ek-/I'G f-Y�l'3 `lg✓(, Q Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City.State,Zip) (City,State,Zip) e Setbacks <br /> PHONE PHONE Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTYILOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Q Elevation of property <br /> ❑ <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL 'Id frontage drawn to scale. <br /> NUMBER 6-20 G - as q- 96-0,TOWNSHIP: SECTION: <br /> U eir rho Vt t c;a 1/4: s ,....._ 1/41/4:S ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3 3671 (�c 5(""1 12 . permits <br /> CSM: LOT v SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Far r S4.r v C.$ 41- ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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) <br /> BASEMENT: 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> Y,000 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ `�-� and available options. <br /> (Please round to nearest dollar) $ W 00 O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I3No ❑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 2No <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 RNNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ - <br /> 545-112(4/08) <br />