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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 /> 5/ 44 &"-G'G ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> ;/6 6-0 EOE /7p. E & Q TO il/ (ii2 s-,P C,P y Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (64:)37,,-091! SH4Aet . tea.? • _a Z •tool ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> NORTHLAND efpjte 'Ai6.S ❑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 /> 44/ _ .pis_S�yz 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 NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> /4. <br /> 1/41/4: El Driveway permits <br /> ADDRESS: (state, county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . ['This project is a new building or structure. • L7 Permitted Use? <br /> ❑This 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 /> LI Wetland/F000dplain/ <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: ❑ ErosionControl permit <br /> 1 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) d` <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ElDon'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 /> 545-112(4/08) <br /> (Continue on Back) ♦ —► <br />