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T <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> D Kfr1/G 1 TL r ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ��pp � Deed Restriction;CSM <br /> K��- /`'� -9�1"�v�t t� c�.�j Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .0: 44 3 D , - e- d t rb Ste w r7t �t rh"-t 1 . 6471 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Se (-1 alit), Pitt " fal4.-4 11.45. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> 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 �'.Zq 3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> $lac c r. et,r-j-h SW 1/4: S� '/.'/4: ?.t) ❑Driveway permits <br /> ADDRESS: �n/1 j (State,county,town) <br /> 53 7 8 yet- g-I� Maze Z04'4M-4 4e (i c4v ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 5 7/ i (public,private) <br /> PROPOSED PROJECT INFORMATION STAII ,REVllrllll <br /> PROJECT DESCRIPTION: <br /> -r,2 Ira 00 Iv/r�� 1e 1 Poo 1 [3 oil <br /> . ®This project is a new building or structure. <br /> ❑ 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 /> Ai/A N/A ❑ Wetland/Floodplain! <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1 ST FLOOR: ❑ ErosionControl permit <br /> N) A jj IA + TOTAL SQUARE FOOTAGE: ,, (Slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> N/A N/-* Fo 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ $ ow) <br /> and available options. <br /> ♦ -+ ♦ —•(Please round to nearest dollar) $ 3 0/ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IAVo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Spa ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ©Yes EVo wo1pri e f <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes slo <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 @lo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes 12NO <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -+ —► <br /> 545-112(4/08) <br />