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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME -� J <br /> Ross 'T,Scz1 `Jt`N ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi(�) <br /> / Deed Restriction;CSM <br /> (O S ti WY eC P Inczorna.),`C VA' S-3'ScO Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> £0,-60--3s 60S-76Y1 25JR, m_,,, ,s co ' ` Core% ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> •J `r i'1 K;rt4 ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7Z2-c L;,,r /III <br /> (City,State,Zip) (City,State,�Zip)/7� .� � �� El Setbacks <br /> J IC , ,/ kb/ j� <br /> PHONE PH NE l ❑Site Plan approval from <br /> U r39,3--C`t3 (f applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> L 'Am LCc- 4.1,CUT) ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: _ CURRENT ZONING: ACREAGE: p Elevation of property <br /> ❑NUMBER 0101`3�13"$fc+7J frontage drawn to scale. <br /> R�\ -Z <br /> TOWNSHIP: SECTION: <br /> R., u ,/4. S ,/,/4: ❑Driveway permits <br /> ADDRESS: <br /> (state,(state,county,town) <br /> 67419? CT's W' ❑Sanitary permits <br /> CSM: LOT SU;•VISION BLOCK/LOT <br /> (public,private) <br /> 3Z. 44 �s4J / S <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> IZES 1-to> �� ❑ Zoning District <br /> . XThis 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 /> HEIGHT IN FEET: EWER i*EPTIC NUMBER Z i 7 730 � (new /existing) <br /> including basement) <br /> Zc3,(a ( LI Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionControl permit <br /> Z0/11 35(0 { TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> 2ND FLOOR 3RD FLOOR: <br /> - filling/access) <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location Survey <br /> (Please round to nearest dollar) ♦ '♦ ♦ ♦ ♦ ♦ and available options. <br /> 3�� ax> <br /> ' A <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ON° "'Don't know <br /> 2. Is there a wetland or floodplain on or near the property? �es to ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes kiNo <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 LI o ['Don't know <br /> 7. Is this to correct a violation? ❑Yes pl o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ ♦ —► <br /> 545-112(4/08) <br />