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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME n çkc <br /> S. As ❑s Zoning Status; CUP; <br /> ORADDRE ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> S41 (._stuv\. tixokvSo.. Y,_ Variance(# ) <br /> HOME PHONE CELL ONE E-MAIL ADDRESS <br /> •• - - •4 1 a ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <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 /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NU BE CURRE ZONI G: ACREAGE: <br /> ❑ Elevation of property <br /> 0 NUMBER o51� _��O' �� frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> if-110,%. t., 1/4: ,/4,/4: [' Driveway permits <br /> ADDRESS:/ (state,county,town) <br /> 56` GT' ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> CANtt_t_IL),. L.ty ❑'Zoning District <br /> . is 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: LI Rural Address <br /> EWER {EPTIC (new/existing) <br /> HEIGHT IN FEET a\ NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: r.--, ErosionControl permit <br /> cb P 4, TOTAL SQUARE FOOTAGE: 4, (Slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 5-0 Q <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ —I. ♦ —1. -1. ♦ --- 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 ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes plNo ❑Don'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? [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? [ Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />