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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 /> L>c . \1 • `.r co dt ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi <br /> Y) 331 1 ..),-,� Pt B m C�a.r^ L" el t,,,1. 53cc Deed cee(#iction;CSM ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 'd$ 775 TV ' ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1 * . ❑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 Z NINGG: ACREAG <br /> ❑NUMBER b(9 t U "Z 3L- 00.111-7- g.r J j frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 11r r '/a: WA: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 7-3 ( C1-4 M3 rk- <br /> CSM: LOT,: SUBDIVISION ?,BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> O ii. V0 eAS <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> eAra ❑ Zoning District <br /> .Q <br /> . 'rhis 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 JEPTIC (new/existing) <br /> HEIGHT IN FEET: /' NUMBER OF STORIES: (Not including basement) <br /> 5 <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) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> 9 o v , TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: C <br /> 0zf <br /> Li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ,l and available options. <br /> (Please round to nearest dollar) J U t (��' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ]Yes EI'o ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IsiNo a on't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes "io <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) Efres 'lo ODon't know <br /> 7. Is this to correct a violation? ['Yes ao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -► <br /> 545-112(4/08) <br />