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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWAME\1 C� <br /> AA :.��-�/-4-k u, ` !__ ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City State,Zip) Deed Restriction;CSM <br /> 1 .4 5 6A HO—L c,-r- V-efoitiA L- Variance(# ) <br /> HOME PHONE G CELL PHONE E-MAIL ADDRESS <br /> / ErSite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME, CONTRACTOR NAME <br /> {.---T j (W1 S w cj l A(/ t ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 46 3eL-11070m wAtii <br /> (DV State,Zip) WI (City,State,Zip) [✓]Setbacks <br /> atl NI PHONE PHONE Site Plan approval from <br /> ( jig— 5-/5- 1 I applicable township. <br /> E-MAlL ADDRESS E-MAIL ADDRESS <br /> 2, e /shoo.(um Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: 7 /` CURRENT ZONI : ACREAGE: P P rty <br /> PARCEL NUMBER D Y dg- 6 S2 2 5 2` v -g'eS X J c7i 2 57 5 f frontage drawn to scale. <br /> T SHIP: SECTI ` i <br /> , �� '/4: '/a'/a: ❑Driveway permits <br /> /y (state,county,town) <br /> AD ES P f, ,©U(zF , t j C t CGVI/all <br /> �S Iv/ty' h I <br /> CSM: OT SUBD VISI N BLOCK/LOT El Sanitary permits <br /> an / r [ p, .. 1 r i (public,private) <br /> PROPOSED PROJECT INFORMATION 1't Ll. STAFF REVIEW <br /> PROJECT DESCRIPTION: kom.€YvQ `o (ofu - k( ( tfVt LI Zoning District <br /> . ❑This project is a new building or structure. <br /> Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER A--- EPTIC 1 "" 7 C1 000 17 (new/existing) <br /> HEIGHT IN FEET: 2_`-7 , -`r NUMBER OF STOR (Not including basement) <br /> ❑ 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 /> BASEMEN 1ST LOO ❑ ErosionControl permit <br /> 0 7 $ Z_6 ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FL R:f� 3RD FLOC) <br /> U"1 U <br /> V 12- 1_r s 7 6, 1% LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -, ♦ -► -01. ♦ � ' �' �� 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 'lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Y-s ' ° ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? il-gk es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Dlo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# /O 72-1D ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ['Yes j4o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► <br /> 545-112(4/08) <br />