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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME C) <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street, Stat Zip) <br /> t,,r). 4 City, -� C`! I i 1 f �� r Deed Restriction; CSM <br /> `� ( Hu , U UiLt.� Variance(# ) <br /> HOME PHONE LL• 0 1� G (,jd E-MAIL ADDRESS 3 D ✓U I `v c3cl 3 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAM: , CONT r /kJ ,-,T NAME <br /> 14 ( Po i 1 4,-- , ['Site Plan including location <br /> AGENT DDRESS CONTRACT DDRESS of well/septic <br /> S `6i -t) CL u i 67 C-(- 2. s / - Co y e, �f z <br /> (City,State,Zip) r (City,State,Zip) _ _ ❑Setbacks <br /> f?�t -f d t vv,.it ex w T �?cb ( M�ei►'T I h/\o-C c z- 6 3 ti 6 I <br /> PHO P or,E ❑Site Plan approval from <br /> Cti`+S� ?0 — �� (o ,� �) �G� j/� �o applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: AC EA E: <br /> ❑PARCEL 1j � I �� �,� frontage drawn to scale. <br /> NUMBER g-643 ^'l 1 0 1—o Q— t o <br /> TOW SHIP: SECTION: <br /> ❑ Driveway permits <br /> ADDRESS: A (state,county,town) <br /> L201 D ,`t St Or'1 <' <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION in -LOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 1U 0 t^-) n 5.1y c c I ti l\ _S T i``._ ❑ Zoning District <br /> . This 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 /> �/ pEWER EPTIC (new/existing) <br /> HEIGHT IN F ET, A NUMBER OF STORIES: (Not including basement) <br /> 21 / f p r,,e._ ❑ Wetland/Floodplain/ <br /> Shorelarnd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT:, c 6 1ST FLOOR: ❑ ErosionControl hermit <br /> / 1./ I/ S ,, TOTAL SQUARE FOOTAGE: ,, (Slopes,disturbance, <br /> ( ( filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 5-1 <br /> jU ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST --► ♦ ♦ ♦ ♦ ♦ //"�� and available options. <br /> (Please round to nearest dollar) 4) `7 A.:: <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ��'" ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Y .�No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es El■ • <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies rd No <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) Elves ❑No Don't know <br /> 7. Is this to correct a violation? Elves . o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -♦ <br /> 545-112(4/08) <br /> • <br />