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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN AME <br /> `+I )w_y- ❑Zoning Status; CUP; <br /> OWNER ADDRESS (NumStreet,Olty,State,Zip) <br /> l2 ) l N v n Deed Restriction; CSM <br /> 5/ 5 )'�'�'� �1- s 3S� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGE,((T NAME CONTRACTOR NAME <br /> fe..). .7 r"‹.-S-- 3 rn C s, oSi-s - Co„ > ,�, .. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5-63 s Ii- .n 3 s t!" -5* <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> 4-4..3e„0,.,a.1-(-- - - 4..$). s 3-577 C.J<v,"u.k--- (-31_ Sass 7 <br /> PHONE PHONE ❑Site Plan approval from <br /> Go - 20-0- -26. l`B 6,06- i5-7G 78 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 /> ❑PARCEL 025 11_ 2a I-92`)o — ]T'ZLz") 2--! 3 frontage drawn to scale. <br /> NUMBER J <br /> TOWNSHIP: SECTION: <br /> 5 o> /fir..,rit- ,; '/4: %41/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> s-i 2 /y Al 60)-1 "/ ct, (-I 5 3J I:Sanitary permits <br /> CSM: L LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ( <br /> .1 b4-i cpcs taw Ici�,wg. a Y n LD ❑ 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 /> W <br /> EER N EPTIC �- (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Y g„...,1-- i ❑ 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: <br /> q ❑ ErosionControl permit <br /> { (< 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: q filling/access) <br /> ` 6 Q ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) lg �SCy • <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Des P2 o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 121Yes I o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ao <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 spo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes jqlo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />