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, C61 lq ■ <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ovvNvAni be Yf 1. ave,_ 1.3 S ❑ Zoning Status; CUP; <br /> OWN ADDRESS (Number,Street,City,State,Zip) pi j _ <br /> y,)03 C r// 5 u u A e. , f w/ �3 5 Y 3 Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL ONE E-MAIL ADD SS <br /> - i -a3- Y7 C n- ri . d C0I oV U S , c L Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACT R NAME <br /> 5, Z /�P �4 ] y LI Site Plan including location <br /> AGENT ADDRESS C NTRACTOR ADDRESS / of well/septic <br /> (City.State,Zip) (C ate,Zip) J/f/ 3, ❑ Setbacks <br /> PHONE PHONE Cc-e.e. i5' 7 <br /> Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> A Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http J/accessdane.co.dane.wi.us/) 4 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: AC EAGE: <br /> ❑ NUMBER Oct-Al ' ip]- 15-4 -3 ii, l 3 frontage drawn to scale. <br /> TO HIP' I SECTION: <br /> L -A b Lev-y d b '/a: N W '/%: N W ❑ Driveway permits <br /> (state,county,town) <br /> AD RESS: <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> 1 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Pi ❑ 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 /> VA a veil: 1ST FLOOR: <br /> 3 <br /> ❑ ErosionControl permit <br /> G��� 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOG : 3RD FLOOR: filling/access) <br /> Cl Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 6-1 6011,a) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes yN,No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes gI No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in a ent? 2YeS ❑No <br /> 4. Has there been a zoning permit issued for this prope ' t on � � ❑Yes L No <br /> 5. Is this project associated with a rezone/CUP/varianc� ilon/apppeal# ) (leave blank if none) . <br /> 6. Is a location survey required? (see reverse) 200g ❑Yes `.i No ❑Don't know <br /> 7. Is this to correct a violation? 41A- 1 N" ❑Yes 1No <br /> ^ N1NGliD li APPLICATION MUST BE SIGNED <br /> 545-112(4/08) DMIE volig( (Continue on Back) ♦ ■ —► <br /> r <br />