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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 /> -1,k 1. Y v1 t. i2( ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,ptreet,City,State,Zip) �/� Deed Restriction;CSM <br /> i-i P30 - E -78 E S / /4' 5.Jz//7 Variance(# ) <br /> //HOME PHONE CELL PHONE, �E-MAILADDRESS ` ,�/ CL J <br /> UAL:' L'2 /i ,./r -ri`J'� e m it ' le IL . �� � /1 'F u Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOF: INFORMATION and includes dimensions <br /> AGENT NAME ; NTRACTOR NAME <br /> '1,45, c' i.A ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) ,iry tan S ,Zip) e ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> (&00 ) a[/_ /1/5 applicable township. <br /> E-MAIL ADDRESS E-MAILA DRESS 7 <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 /> Li PARCEL 42—f.p& X22 C() 0 G 6_ kA I. 3 c frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> iO (Zi '/a: %IA: ❑ Driveway permits <br /> / � (state,county,town) <br /> ADDRESS: "u; 0 51L, If kwoy 8 <br /> CI Sanitary permits <br /> CSM: LOT SU DIVISION <br /> BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> `7 - L4 � j, 4 IT--;y,6'i ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> yl This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: ' NUMBER OF STORIES: (Not including basement) <br /> 1 U Wletland/Fl�plain/ <br /> Shoretand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FI,••-: <br /> /' j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> o kilF�- filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> qso Nfi' 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: /`fin and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ S (90 9 WC <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes A No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No A 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 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) ❑YesNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 1'No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —r► <br /> 545.112(4/08) <br />