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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> �-e r rL L 4 I+�J ( CK\ ❑Zoning Status;CUP; <br /> ow R DRESS st mt,city, te,Zi Deed Restriction;CSM <br /> E0 � E-MAIL ADDRESS �l�) ( Variance(# ) <br /> i' Ill'ili D, ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ON CTO E <br /> '�' <br /> 01111-.16 16 in :Site Plan including location <br /> AGENT ADDRESS C D SS of well/septic <br /> 1,\,)�vJt ii iza <br /> (City,State,Zip) El Setbacks <br /> PHONE PPE t I <br /> D Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (h ttp://accessdane.co.dtane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: p CURRENT ZONIN • ACREAGE' <br /> LJ NURC ER a-f Z3)�{ 6 Oo Lj ,'2 J ► LP frontage drawn to scale. <br /> TOWNSHI SEC )N: <br /> ( t 1 A .7 ( '/i. lh%: ❑Driveway permits <br /> Aco h i Q-. el ( s2 (state,county,town) <br /> CSM: OT SUBDIVI ION BLOCIVLOT J ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: .` tAfbLti I di <br /> ❑ Zoning District <br /> his project is a new building or structurev ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER PEPTIC �i (new/existing) <br /> HEIGHT IN FE I('ti((J NUMBER OF STORIES: (Not including basement) <br /> 1I ❑ 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 /> ❑ E ; tro t <br /> BASEMENT: ' � 1ST OO <br /> W r j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> _ 304` <br /> � <br /> -1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q I) ,l Q • and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yes ►f o Don't know <br /> 2. Is there a wetland or floodplain on or near the property? []Yes ,1 o 0Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? s U o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes , o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) []Yes 1��*o ['Don't know <br /> 7. Is this to correct a violation? []Yes 'S o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -i —► <br /> 545-112(4/08) <br />