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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 /> 'ILL ACKt-Mfr. 5K( C Lt't 6 aZoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 1011 8 L.Ac c NA(.i'( ROAD/ DDU 7 O 1J, W( 53 5-6Z- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6)0E3-33'4-.26/6 ToeuEskattnA ke - /natl.coop <br /> [Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> N A L jz ifVMOIe..S 'Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) R Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. /VA- <br /> E-MAIL ADDRESS E-MAIL ADDRESS J_ <br /> []Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: .t.�� ^L P P Y <br /> PARCEL Q + f frontage drawn to scale. <br /> NUMBER 07a8-lit- 090°04 REc Knoll . . <br /> g <br /> TOWNSHIP: SECTION: 1'7 -r 7//Q i� <br /> r/11 DO L ITO,4 5 b✓ .1/4: N 'E- .1/4.1/4: ['Driveway permits A/A- <br /> ADDRESS: (state,county,town)__ <br /> IO1v6 V)LACk c(.ok gO . 'CA to Co A or l i WI 535'62 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits , /� <br /> (public,private) �_ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> E QUI em gNT 6A2A6E_ 1 co' X 30/ ❑ Zoning District <br /> NThis 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 /> [EWER [)EPTIC NA- N 011 E D E y (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ONE ❑ 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: <br /> I—, ErosionControl permit <br /> 4. TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 60 T Z <br /> ❑ Review Location Survey <br /> • ESTIMATED ED CONSTRUCTION)COST: ♦ ♦ ♦ ♦ ♦ ♦ �� ) 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? EKes [ENO ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? v❑fes ENO ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Oes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Wes ENO <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 I2Ko ['Don't know <br /> 7. Is this to correct a violation? ❑Yes v❑flo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -* <br /> 545-112(4/08) <br />