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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 /> PO ef f Cin"q n ov ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 7302 ,1 ev(ow /'.'/�try igcl Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 'a 2,: V6 -9691 NS. chciorolov 011; <U" ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> sr/f ❑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 ZONIN : ACREAGE: ❑ Elevation of property <br /> 11 NUMBER 1,5701,570c9� ,0 L3"TS R^ 1 40_82 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> T°N,••1 of AI)eili/(76°' '/4: ,/4,/4: El Driveway permits <br /> ADDRESS: <br /> 7 �a) V 177 (state, county,town) <br /> �O 'Z ��eac <br /> CSM: LOT SUB IVISIOr_ BLO LOT ❑Sanitary permits <br /> 12 ' i ' 4 Wel (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: • � <br /> S4 reel /0 x/6 ❑ Zoning District <br /> MThis project is a new building or structure. ❑ 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 /> /J. ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1 ST FLOOR: ❑ ErosionCon$Ol permit <br /> /4 0 I 4, TOTAL SQUARE FOOTAGE: ,, {slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 40 filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION)COST: ♦ ♦ ♦ -► ♦ d �t000,d v and available options. <br /> (Please round to nearest dollar) <br /> The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies ZNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 121No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? res ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ./... ❑Yes IINo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#Z(b,' ) (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? Efres [ No <br /> APPLICATION MUST BE SIGNED <br /> Continue on Back)(4/08) ) <br />