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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CU-TOMER TO PROVIDE <br /> OWNER NAME /'/' <br /> ID U - _ci h �� k / / IR Zon'ng Status; CUP; <br /> OWNER ADDRESS (Number,Street,City, 'late, ip) <br /> it,3 Fel . De:d Restriction; CSM <br /> HOME PHONE CELL PHONE - ADDRESS <br /> Va ance(# ) <br /> r it Plan drawn to scale <br /> 1oD : • .. 5°'"'"`Q , r ._ rn,� . .S' . � ;Mai �.•, <br /> AGENT INFORMATION CONTRACTOR INFORMATION a includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C_CS t Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of ell/septic <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE ❑Site Pla pproval fr m <br /> applica le tow Ip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n Floor p ns to s to <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevatl of property <br /> ❑NUMBER oat O -�� N WOO a -. c Y) s. )3 front a draw o scale. <br /> TOWNSHIP: SECTION: <br /> r U.U.0 ke. 3 5- /: k.),E '//: SW l <br /> ❑ Drivew per <br /> ADDRESS: p (stat co y,town) <br /> i 3 4 r-Q-�(& c R� (s c5et t� t - 37/d ❑Sani permits <br /> CSM: ' "T C LOT p SUBDIVISION BLOCK/LOT (p Ic, private) <br /> v L <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: jj <br /> L eGJA -TO Cl n e_x l 'fn�} b Ut l�t 0�'/0 L 'oning District <br /> This project is a new building or structuK (J 11 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural 'dd -s <br /> EWER lEPTIC ' (new/ isting) <br /> HEIGHT IN FEET: /? a NUMBER OF STORES: (Not including basement) <br /> Y (/ ❑ Wetland/FI plain/ <br /> Shore d (att hment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: <br /> ❑ ErosionC trot permit <br /> T: <br /> © 4 TOTAL SQUARE FOOTAGE: 4 (slope disturbance, <br /> fillin access) <br /> 2ND FLOOR: 3RD FLOOR: O <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ /N-`oO 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 ®No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 1 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes 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) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Lives ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) ■ ■ -♦ <br />