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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME/ r 7:), J <br /> C. �^a I et ± s Actr'0 hA, Nr� Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> m �} ! Deed Restriction; CSM <br /> 74�- 4a tit/ S v'//(e / .:4 , L- 'f c- f a/ns,/d/, .5�a_5 variance(# ) <br /> !ME P ONE CELL PHONE J E-MAIL ADDRESS i A <br /> l00� le •• I-� <br /> _ / Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> s4,521v�. f/'0.0.De1l <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ["Setbacks <br /> PHONE PHONE [Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Q Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ErElevation of property <br /> ElPARCEL frontage drawn to scale. <br /> NUMBER d$o1- tgy- 85s°-% - te? 40.3 k- <br /> TOWNSHIP: SECTION: <br /> ,3 Z--( 13 1/. ,/1/4: g Driveway permits <br /> ADDRESS: (state,county,town) <br /> ®Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> =F � .AcC Ssoc( ss�rte. 3 n X s CI Zoning District <br /> . <br /> This project is a new building or structure. ❑ Permitted Use? <br /> 0This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> a�' / ❑ 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 1 ST FLOOR: 1-1 ErosionControl permit <br /> / 2 '7 /(J� 4, TOTAL SQUARE FOOTAGE: 4, (slopes,di <br /> (, °C sturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> /�. ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) 'P U-J, C CO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes RNo 0Don'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? Dyes ONo <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 QDon't know <br /> 7. Is this to correct a violation? QYes ONo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ -i <br /> 545-112(4/08) <br />