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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 /> �G n (--t- � ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> `—t l0 3 0 r'�� �� Variance(# ) <br /> HOME PHONE CELL PHONE E-MISILADDRESS <br /> 6C16-"47-W (P ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME _ <br /> �bt /� �')(I '(,t PAZ ❑Site Plan including location <br /> AGENT ADDRESS ONTRACT R ADDDRESS of well/septic <br /> 35RO ti) ti46f e <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE CP ��� ❑Site Plan approval from <br /> 666) 85? 66g0/ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ( / ❑Floor plans to scale <br /> ctCAUO. u.ed . I /1/ta, <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CU NTZONING: ACREAGE: <br /> ❑PARCEL 1 6 (�`� frontage drawn to scale. <br /> NUMBER �I8/(l2//°(1J-4 d�OS�-ter' �/ V J <br /> TOWNSHIP: SECTION. <br /> Cai • <br /> n i✓G ' : % : ❑Driveway permits <br /> �� ��� (state,county,town) <br /> ADDRESS: <br /> t <br /> CSM: LOT �/ El Sanitary permits <br /> SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Add cj(,/`t,/)rOdM +o ex,` as rii/7,at` ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> 0This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> [EWER ,EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> our /1-1 Qy, r, n__e / ❑ Wetland/Floodplain/ <br /> AREA TfO�N i NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: / q& 51/ <br /> 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> r `(�L filling/access) <br /> v t ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ _ and available options. <br /> (Please round to nearest dollar) $ /5-6w <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes So ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes ,lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? s OVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? /—❑Yes ,o <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) Efres ,610 ['Don't know <br /> 7. Is this to correct a violation? ❑Yes /Jlo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -1 <br /> 545-112(4/08) <br />