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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 /> Clj,. 5 J','lx� R.,j Co � 1 :), 'TEA 0^7,(' r� Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2e- C C lei, /I / &"O� .2/'-1-u_I l-11� 5'3 ;3 Y Variance(# ) <br /> HOME PHONE 7 CELL PHONE (/ E-MAIL ADDRESS <br /> keo. ■ 4 0$ Z II-2,e3 Mai v e ....el Ccc.e.a ,....:,:i. Site❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ecy:.1. ( �P.,.( f L.L C ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS / of well/septic <br /> 2, 9 a TQreci C4. C4 - ( 2 <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Ste„ PeA.;.- . � 1 S36 ? 0 <br /> � <br /> PHONE PHONE ❑ Site Plan approval from <br /> Lb(' Q 2 S - 7.9 7 'S applicable township. <br /> E-MAIL ADDRESS E-MAILADDRE <br /> /11 a,I Go► .4 n I , .. 1, Co, ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> 1:PARCEL PARCE NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL 62,PARCE all-AY-140-1 A-tCcx)i gt4- 1 3 g , '4- frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> , k; . k 26-5-(I Y4:S6 j,, 1/41/4: ❑Driveway permits <br /> ti <br /> (state, county,town) <br /> ADDRESS: 2 '/ ( c nZ 1 14, 6 rTWA Y A <br /> CSM LOT SUBDIVISION BLOCK/LOT El Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 'Po• ( ❑ 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 VEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Vlletland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: • 3RD FLOOR: filling/access) <br /> (-I ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --► ♦ ♦ ♦ /I/ and available options. <br /> (Please round to nearest dollar) 3 , fl! <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑No DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [ Yes ❑No [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 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 ❑No ]Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />