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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW' R NAME <br /> r'dDvf Q t( vVe Ci ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, p) Deed Restriction;CSM <br /> i6iy,C/ ST-re Ved`cd A R3c(c Q Pavt, tit/-� c--y<—zee Variance(# ) <br /> HOME PHONE CELL PHONE E- AIL APDRESS <br /> td 83-0--3$ ('' 64-66 r-7A 1(6 • baV we " 0.'&5 /1 ..'t ❑Site Plan drawn to scale <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/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL Z _Z y/ frontage drawn to scale. <br /> OJ <br /> NUMBER O Ct 2 L tiO- 0 ✓ <br /> TO�W'SHIP: SECTION: <br /> `(oLv'n. of anc 1/4: '/<'/4: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> ' Pa f1 e is f o►, Roc. <br /> i>ct v!e V-'2 C?5 Z ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOC LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO T DESCRIPTION: <br /> he ❑ Zoning District <br /> . NThis 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 /> EWER SEPTIC (new/existing) <br /> HEIGHT ISA FEET: NUMBER OF STORIES: (Not including basement) <br /> l g ' I ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> O Q o +, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> `..-__f `.-----" e®® ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ p� .0— and available options. <br /> (Please round to nearest dollar) a 80 <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 EINo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ElNo <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 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes J to <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -. -+ –► <br /> 545-112(4/08) <br />