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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 /> " r.Gee/ da ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) /� Deed Restriction;CSM <br /> 7, �L ,�� ` G/r 4 ?T55..z Variance(# ) <br /> HOME PHONE CELL PHONE E-MAI ADDRESS <br /> - -&Pe 02775/ f 41/e. A' ,A.' w ' p Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /6,Lie.j te.,-;42/.:0�,Lyc, 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTQK ADDRESS of well/septic <br /> 3/G i r7'fi'J I rc ,z)/- <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> I/, ®/t/e 7 'T 63/ '9 <br /> PHONE PHONE - / ❑Site Plan approval from <br /> -077e 5/y -3 y applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS � <br /> y, -_ ,, , • i w Ttli/cogG.. Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 3 ❑Elevation of property <br /> 0 Q ? frontage drawn to scale. <br /> .J <br /> NUMBER i Di i /_ i A , J �.. _2 <br /> TOWNSHIP: SECTION: <br /> ni/VIII 066,/h,Q.� /O ' r 1�4: 5 1,,,,,: ❑Driveway permits <br /> O (state,county,town) <br /> ADDRESS: <br /> <a76. r/D.�.,,q a i9i` ,/-/CA;,-14,140////--.. .3-t34" ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /96/1 , ❑ 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 PEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ca ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outsid dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> "A + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: /�� 3RD FLOOR: <br /> filling/access) <br /> - /.S3 -S-3l0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --0. ♦ ♦ -+ and available options. <br /> (Please round to nearest dollar) s.3-me <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EJYes ao ElDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Jo ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? :Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ['lo <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) s ao QDon't know <br /> 7. Is this to correct a violation? Yes [lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ■ — <br /> 545-112(4/08) <br />