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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME _—i/ <br /> - eve $c ye . <br /> ❑Zoning Status; CUP; <br /> OWJJ ADDRESS (Numbe, r et,City, ) Zip <br /> / r(15 JUG ��f , )j Deed Restriction; CSM <br /> G115 I V l ) Variance(# ) <br /> HOME PHONE CEL HONE E-MAIL DDRE <br /> -33 3 Je Z U a C ° C0 rv'1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAM <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRA -•R ADDRESS of well/septic <br /> (City,State,Zip) .(City,State,Zip) ❑Setbacks <br /> PHONE P .. ❑ Site Plan approval from <br /> . <br /> applicable township. <br /> E-MAILADDRESS / E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONIN ACREAGE: <br /> ❑NUMBER 0 CO 6-26 I e(29 i 9— J'L` � h-' t .- (o Z frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> �"ocJr) / nr 90 .1/4: ,/4,/4. ❑ Driveway permits <br /> ADDRESS: E7 �J 1 (state,county,town) <br /> I/ C� r& W I <br /> CSM: `7 V� �y ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: l t <br /> pr. k J 0 7C Z 0 ❑ Zoning District <br /> . <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 /> [)EWER {EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> — ❑ 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) Li 1--. permit <br /> BASEMENT 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ZOo <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q �� and available options. <br /> (Please round to nearest dollar) 'P / ( e i - <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes .15No ['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 year ? Yes No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# (2 ['Yes <br /> Z� ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes rii 'Jo ❑Don't know <br /> 7. Is this to correct a violation? ['Yes PI o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />