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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to wee-App* <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA <br /> -,//2. , �Y1 ,(,#' ❑Zoning Status; CUP; <br /> OW E LADDRESS (Number,St e, ity, -te,Zi ) <br /> � J� Deed Restriction; CSM <br /> PRONE 2 /Y/ .47 ��.Ifez , - _ ��/f J� ����� Variance(# ) <br /> HOME P ONE .'PH E- AIL DR S _ <br /> 1 I .1 - j /^ ,T .„5,-,,, ,.ft, i• .- 'El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> )c ❑ Site Plan including location <br /> AGENT ADDRESS CONTRAC �R AD RESS / A ,---, of well/septic <br /> (City,State,Zip) <br /> Setbacks <br /> to p)/ _���� �/n� 5.-- --S-2' <br /> PHONE PHON <br /> ❑Site Plan approval from <br /> >( r ',.3 -D,30 applicable township. <br /> E-MAIL ADDRESS E-MAIL DD'ESS ,4'/ _j �I <br /> ` . L�:� Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdare.co.dane=wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL A frontage drawn to scale. <br /> A <br /> NUMBER - I O.q 4$ i►c- <br /> TOWNSFIll SECTION: <br /> /4: 1/4,/4: ❑ Driveway permits <br /> ADD''-'-, � % � (state, county,town) <br /> �j&1J �( , I, �4e'� —5SP ❑ Sanitary permits <br /> CSM: L'4T ' S DIVISI N BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECP9ESCRIPTION: <br /> M 0,66-Y ❑ Zoning District <br /> . OThis pYoject 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 /> JEWER JEPTIC (new/existing) <br /> HEIGHT IN FEET: j 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) <br /> BASEMENT: 1ST FLOOR: I—, Erosion Control permit <br /> 1 TOTAL SQUARE FOOTAGE: +, (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> I 13 Ifi Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ , and available options. <br /> (Please round to nearest dollar) �(! / <br /> St: u8 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ..� ❑Yes Etvo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property?...4. Elves ❑No EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement?p d Wes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years'? ..1/ Des ❑No <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? ...4./. Dies ❑alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -► <br /> 545-112(4/08) <br />