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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME l'"2 p jTl - f <br /> L /ig/� ! ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,C'ty,State,Zip) _ <br /> J 36c t� 1 l t y 9 OP iv I- Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME _ <br /> R .,1 G E- albf ;i ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /131Z OfiShylr1)Ur7 a , <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> 6 t &rL', &I S 353 y <br /> PHONE PHONE ❑Site Plan approval from <br /> 'f%4 . 77I/-a3/< applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / <br /> '� L ` L F i l 7f 6 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn [1 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZO NG: ACREAGE: <br /> ❑NUMBER f�S72- D7-L f �S-?0'0 it 1�`Z q. p B frontage drawn to scale. <br /> TOWNSHIP: L b 1 t1 SECTIC�jJ: <br /> �1,J �[L ,�4: ,�4,�4: 0 Driveway permits <br /> ADDRESS: f (state,county,town) <br /> 1 ,j I L1-0 �, 1 1121114- L L & ) g,,, .)1 533,3`;) ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> S' i 1 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 4/0145E- ❑ Zoning District <br /> . ElThis 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 JEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 1---1 ErosionControl permit <br /> r ' 1 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> - filling/access) <br /> 2ND F OOR: 3RD FLOOR: _ / <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ ♦ r and available options. <br /> (Please round to nearest dollar) ti <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eves ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es �No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Res <br /> ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Oyes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# C070 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ENo ['Don't know <br /> 7. Is this to correct a violation? Dyes • i4 No <br /> ' APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -0 <br /> 545-112(4/08) <br />