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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> To i/liA ty ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,Sta e,Zi ) /`. 1 Deed Restriction; CSM <br /> 7‘ - VI La S C04113_4 l7t'd�/'Q W Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL DDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ear W _ n Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> t `1 `7 I-�a v'v i -- Lam <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> bc-�,--c 0 f t WI c3 s-3 Z <br /> PHONE PHONE n Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/4: 1/41/4. ❑ 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 /> Zoning District " ' <br /> . ['This 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 /> EWER r)EPTIC (new/existing) (w�f; b <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Wetland/Floodplain/ 1.-Wb,k <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: <br /> Erosion Control permit <br /> ,l TOTAL SQUARE FOOTAGE: 1 (slopes, disturbance, --0 <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 6 -C) Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ //j �Q0. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? nYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? nYes fNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? jYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves ❑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) Elves ENo ['Don't know <br /> 7. Is this to correct a violation? Efres ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) - <br /> 545-112(4/08) <br />