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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 /> ^A <br /> Pt ce C r�� w/ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 75 2 7 tic '-/ft's. a�Q 62-)c.c,,,k 4J< 5-3 s- 7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6co- 22C-- 2 Y3 ? / //c .C'G.h./. �, <br /> `�r` '` ��4� ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑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/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL G frontage drawn to scale. <br /> NUMBER g 6' - /73 To)/- 7 Al /rx rl r••-• ?c g <br /> TOWNSHIP: SECTION: <br /> Sapr" "�;r/a' I/4. ,/4,/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 75 2 7 /-r - kq 6.,. �� 4o,_- _-/-, 4�c- 5-35 9 7 <br /> CSM: LOT SUBDIVISION BLOCWLOT ID Sanita Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Sh«P Y,,( 7 Cl ❑ Zoning District <br /> El This 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: Cl Rural Address <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 4/ ',c.. ❑ 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 /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 2a'&o <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ —I. and available options. <br /> (Please round to nearest dollar) $ 2C� 3 C G� p OnS. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres ao ❑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? Elves 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? ['Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />