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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 /> /4c).W1 k)e 1 eil s-t,r ❑Zoning Status; CUP; <br /> 0 ER ADDRESS (Number,Street,City,State,Zp) <br /> 4-3dr— .S't'o¢1e. 12.4_ Surt^1PCoaSrX. LAS fi 559 0 Deed Variance Re(triction;CSM ) <br /> Variance # <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> •:-S 7'7-'7(,i1 awerscnccl e 1 Avt-• C'G ❑Site Plan drawn to scale <br /> AGENT INFORMATION I 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-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 45$/©91 1-41t3-11093.5 A I- x , frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 50N 1?ekkts,.le_ 1/4: '/a'/a: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 53625- S Mg.t- ed- SOOfr'aSi'- V33' 5f 0 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> OE Vet GMARTE Zoning District <br /> . 1211This 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 )EPTIC ( ew/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ■ ►°t'` Wetland/Floodplain/ 1414 <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) Erosi f trot permit <br /> BASEMENT: 1ST FLOOR: may, ►4 <br /> Q ,c 5 0 + TOTAL SQUARE FOOTAGE: ,' (SIO+ ,. rbance, <br /> 2ND FLOOR: 3RD FLOOR: fllling/a ess) <br /> 00 <br /> g Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �^1 and available options. <br /> (Please round to nearest dollar) p(�s �v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes I '4o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ErYes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes Elio <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 slo ['Don't know <br /> 7. Is this to correct a violation? [Yes [slo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />