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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 /> TOS\thu°. Zt IhMe rs n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, ip) peed Restriction; CSM <br /> 8a3 v 1 S-t 14 t<d 3 c'_ Th T f{0 rrL, w.0 S3574 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR,ESS <br /> (o SAY 9 / 6 $QM e V OS�njq 2,tvr,,L"- )hd.f Ih4I/,6cr..DSite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5a"e ❑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.usl f <br /> PARENT PA EL NUMBER:h, RRENTZO G: ACREAGE: of property <br /> ❑PARCEL A '� e t— 1101 - ,:-.-- 0`1 Si frdntage drawn to scale. <br /> NUMBER \.J�`,Fjl �-'ra� LJ s � i <br /> TOWNSHIP: Fy5^ ECT t <br /> .S Pr i .9 D is i-c--- <br /> 1 '/a: j N.) '/a'/a:,.S 0 Driveway permits <br /> ADDRESS: (state, county,town) <br /> e(c4. Hwy G <br /> CSM: LOT SUBDIVISION BLOCK/LOT © Sanitary permits <br /> / (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE9.T D PTION: t / <br /> I 11 OM e Co r.St r v C�f o r (r' j • (-�(�,� © Zoning District <br /> . <br /> This project is a new building or structure. ttt Tr N- <br /> 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 / '��3 ''r-U I ^O C) ! © � (new/e`x isting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 11 ❑ 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 /> (:)(: .,,,s ,, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 7,,,.. ...... <br /> filling/access) "; r \ <br /> Li Review Location Survey: <br /> ESTIMATED CONSTRUCTION COST: , tj and available options. \ <br /> (Please round to nearest dollar) ♦ '♦ ♦ —• —• —• 3�0 i 000 <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 po ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes [lNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes QNo <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 IXINo <br /> Nit APPLICATION MUST BE SIGNED <br /> 545-112 taioe> � � (Continue on Back) -♦ -► -* <br />