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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 /> Pea' Si orrnoen and p4mq 71 ?/ S�/rnE `7 ❑Zoning Status; CUP; <br /> OWN DRESS (Number,Street,City,State,Zip) ' / Deed Restriction; CSM <br /> 50/0 C��u,-7 ), 1I �uik�p /V Sure Variance(# ) <br /> HOME PHONE ELL PHON ' _ /E-MAIL�ADDRESS <br /> ,68-g37-3V ,• 0— �osQ6 a ake/AP rDn-1-, er, (r)m ❑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-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG : ❑ Elevation of property <br /> ❑NUMBER // - 33/86'-9 A-Z(E-x) frontage drawn to scale. <br /> t2 <br /> TOWNSHIP: SECTION: <br /> 3 C rl rat:, r,E- 3 3 1/4: EU LU 1/41/4; ,,OE ❑ Driveway permits <br /> (state, county,town) <br /> ADDRESS: �� / c <br /> 6-‘)i° C0 64-41 4 h`i4 rlGc'Q,y Jc-0Y / C(1' riHi �/ s3 S9& ❑Sanitary permits <br /> CSM: / LOT / SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Add /1'A'/ ZDe k a)her o A717.0 e.th S- ❑ Zoning District <br /> . ['This project is a new building or structure. LI Permitted Use? <br /> IEThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER 1-, EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> <l ---470'l- ❑ 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: 1 ST FLOOR: ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> /9A ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ n and available options. <br /> (Please round to nearest dollar) (/ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EINo ❑Don'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? Dies RN <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 0No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes [:RINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -+ -♦ <br /> 545-112(4/08) <br />