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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 /> ..c+« #14 0 L's-' ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number Street,City,State,Zip) ,‘ Restriction; CSM <br /> /79a-6 e.�St/� • �- 44/:5 41/, bt) -- 5-3 s3_9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> o-ties- /6 L// )0 - 9Y.?_/C vi ^S',,1Sellilc1..J0,gLN«,.l co i-,-) ❑Site Plan drawn toscale <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 NUMBER: CURRENT NING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL opt Z 3 3(9/.5-0 �� - q / frontage drawn to scale. <br /> NUMBER I(o <br /> TOWNSHIP: SECTION: <br /> „n�C-t A c ,/4: 1/41/4: ❑ Driveway permits <br /> ADDR SS: (state, county,town) <br /> V 9) 6 -reQvl f4 l2 Ar,5G14/1 14J 5-35-5-9' ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3 3 e1 I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> G r ,-, 5/led rep is«144e 4 f LI Zoning District <br /> . ❑This project is a new building or structure. <br /> Permitted Use? <br /> ❑This project is.an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FTEWER E)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I D / LI 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: <br /> ❑ ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access)sYf ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ i 6)0 - <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? Ekes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [Yes ENo <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) ■ ■ -s <br /> 545-112(4/08) <br />