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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM - • <br /> cl,/au6S -relt,x-sy/121 9` 7)j.Qn1.1 L(1/C/C ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> /741;0P ZydA) L•10,116- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 33Z 3 4 :gP 532' 3 ibCS) ,Cey45'/a/C.-s 9frPH17*,eAo7s, ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1;eA149ON 2n ,$ `,)C.' ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7 L26P0r a',qD <br /> (City,State,Zip) (City,State,Zip) , ❑Setbacks <br /> C/OmOp/n6c, („1II j':13 Z3 <br /> PHONE PHONE ❑Site Plan approval from <br /> 0)2 7 /_5-ZzZ applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> Al ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> �A RENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL i//2 i1 /6 r� ��` Z, C frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: %��: clK J <br /> ❑ Driveway permits 6.20, 29 /: ,S4.) <br /> ADDRESS: (state, county, town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ! r� <br /> Rite ,emu/c.o% g71 T yX ! 2 ❑ Zoning District <br /> . his project is a new building or structure. permitted <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER C Rural Address <br /> FIEVVER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: �� NUMBER OF STORIES: (Not including basement) Wett tt lFtt ti in/ <br /> AREA TO NEAREST SQUARE FOOT: tK3feiafltd (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ErosionCOntrol permit! <br /> BASEMENT: 1ST FLOOR: <br /> 2.1e 6 ?1/ ( ) 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: d �It�g/ �) <br /> LI Review'Location Survey <br /> ESTIMATED CONSTRUCTION COST: ,� Srtd avail available options. <br /> (Please round to nearest dollar) '♦ ♦ ♦ -, ♦ $ drf <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Ets No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 21(lo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ls ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes [(]rio <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) [Yes C No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes [rlo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -+ -► <br /> 545-112(4/08) <br />