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TO-heN V t vOrbl 31' ( SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN NAME <br /> (A 11 C' c L YJt°r ['Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi d Deed Restriction; CSM <br /> { �� ✓� Ou C Variance(# ) <br /> HOME PHONE CELL PHOrNEE E-MAIL ADDRESS <br /> k :37-943 c5106 3 i a5_ ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> H Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) n Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n 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 q q frontage drawn to scale. <br /> NUMBER ©`9��^ cI� /R��'� ��/ . <br /> TOWNSHIP: V" SECTION: <br /> ,/. 1/1/. ❑ Driveway permits <br /> 4. 4 4. <br /> ADDRESS: (state,county,town) <br /> C9c,(09c 1/ <br /> Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJ T DESCRIPTION: <br /> r61,5-cG \c, le, .7 to Id !1✓)) ❑ Zoning District <br /> . Rfhis project 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 /> FIEWER IEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I d i 1 Wetland/Floodplain/ <br /> O AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1S FlOOR: ❑ ErosionControl permit <br /> 0 4, TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 2 filling/access) <br /> J 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: / ( ��� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ (p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 'lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es 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) Ekes 2 o ['Don't know <br /> 7. Is this to correct a violation? ❑Yes Q, o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4108) <br />