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r1 , 2 � <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �J <br /> T/4 C-k 6 L r-5A- J o u r✓4 ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 535-7'3 <br /> 3 9'/ 6 o r ti �12.ONr4 Vj- Deed Rce�#iction; CSM ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 00-Lit/Lit/ `D C Ya ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /7)rizie f l/",aa av tJoi,ty F2 e_E �er-� <br /> T ❑Site Plan including location <br /> AGRIT ADDR S CO RACTO`�II�DDRESS of well/septic <br /> Pb 10,c ?3 a if t, 2 PO /i Y30 VV 1 a <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> V.vzokiA- t S?sF3 ✓ft eoA-ifq le/-r 335 /3 <br /> PHONE PHONE ❑Site Plan approval from <br /> Sl 3. -5-4 5-6 S/-3 -5654 applicable township. <br /> E-MAIL ADDRESS Ce"OE-MAIL ADDRESS <br /> a 4, ■ �r e�,,, ,L El-Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 2-Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 3 - frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> '/4: '/4'/4: ❑Driveway permits <br /> ADDRESS: Cf / Q o /J (state,county,town) <br /> 3 I �oTh y ' a,'44 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ,,STAFF REVIEW <br /> PROJECT DESCRIPTION: A <br /> K,610 L,4-c FL G i'" Zoning District <br /> . ❑This project is a new building or structure. 0 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 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> U 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: E t <br /> roslonGont�o permi <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: e t oor:Ll�'�,� filling/access)° <br /> �J-6 SS o tti 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: an i available options. <br /> (Please round to nearest dollar) ♦ ♦ .4. ♦ ♦ ♦ $t�N ©/ d��•too <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? @Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ]No <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 No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes j No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -9 <br /> 545-112(4/08) <br />