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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 /> J tfY 4 i4 lalECLE GU.I4(1N ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> /575 ,STATE go . 'e fill. liar 8, to 5.36-72 variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> De - 3 - V 206E ,pfd 2Z �oryy rt eM ol fe• at ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /V d AM. ❑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: CURB NT ZONING: ACREAGE: ❑Elevation of property <br /> ❑NUMBER °COCO L/,I 5-000 �N - 3 3 c IC. 2Z <br /> frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> , 1 : ❑Driveway permits <br /> tRlz St r4: Ale <br /> r4 r4 <br /> ADDRESS: (state,county,town) <br /> /513 STr4 TE p.o. 7f? <br /> ❑ <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> 017/6- I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> COP 3r/Lucrit AJ OF PeTi)e/1 0 G,1 6,11246e 5Fj/iND Roby Li Zoning District <br /> . ['This project is a new building or structure. Li Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: i NUMBER OF STORIES: (Not including basement) <br /> /s ' Li 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: 1ST FLOOR: ❑ ErosionControl permit <br /> /SOO ,, TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 1200 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 2 Sj IWO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres E Jo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres Eto ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ©Yes o IN PQo GRE SS <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres lato <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) Efres Elo ❑Don't know <br /> 7. Is this to correct a violation? [Iles [✓ to <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />