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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER IME n <br /> RA'i"GE p4a(40 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3B b2, S s) La4.L Col-to&-e Gina£ yr 535-.)--7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> t" g )°9-e)73° ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /i jw�? C,wc1.,A1J'-- .L b147 1'(Lk-°"7 ❑Site Plan including location <br /> AGENT ADDRESS / / /� CONTRACTOR ADDRESS of well/septic <br /> 41 7"c' 13,-c ck Ly c IL/� <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> n2 4-0(1u- 11 S. S3`)/P <br /> PHONE PHONE ❑Site Plan approval from <br /> (e v B c ' L73° applicable township. <br /> E-MAIL ADDRESS ''// E-MAIL ADDRESS <br /> 1,),/�os c it.4, aa� ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 0 15'/O 711 )/j 3318-7 ,S3 Jo frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> CC/ Groin ,).-/ '/: 1/4i/,: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 3g 02_ 94. ) 44'41 i ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ,LIT �$ (public, private) <br /> S kyµ/-ms 54/1_ g,: <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 3 se.0,�. e.,.k_ ❑ Zoning District <br /> . Efrhis project is a new building or structure. 4v 0r T,1 <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> i-TEWER prEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (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 /> BASEMENT: 1ST FLOOR: ❑ ErosionCOntrol permit <br /> 1 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 3 r0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: v a and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ l0 ,33,:,- • p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [ to ❑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? Rles ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 1Yes ON <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# in ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Lives ❑Don't know <br /> 7. Is this to correct a violation? Yes No <br /> Elves <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) --+ <br /> 545-112(4/08) <br />