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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / v <br /> ['Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,S to Zip) _ <br /> ` Deed Restriction; CSM <br /> ► 1 <br /> &o a id o y 5 H H /�a',r, C Yi 4< C3 C 96'" Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> i - g-17 -7 3r5f ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME /�- CONTRACTOR NAME r <br /> 'J ce`- Z h Pte' 5-/tz u ry P6( , /40v4 ❑ Site Plan including location <br /> AGENT ADDRESS / CONTRACTOR ADDRESS ( / of well/septic <br /> 7i /7 w; ) L( ✓/j (J/ // <br /> (City,State,Zip)/ (City,State,Zip) ❑Setbacks <br /> A H 1717a1/; el L'Z 5'310 <br /> PHONE PHONE ['Site Plan approval from <br /> •og.-2 7q--7a c /' applicable township. <br /> E-MAIL ADDRESS / E-MAIL ADDRESS <br /> ie /i2 ri(� �/C / q/h G0, e 0,1 ❑ 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 , j / frontage drawn to scale. <br /> O ' <br /> NUMBER 1' a 2S 4-)-D A---( I. Z <br /> TOWNSHIP: SECTION: <br /> BY S ( � '/4: 1/1/4: [' Driveway permits <br /> (state, county,town) <br /> ADDRESS: n n <br /> a 96 O M iii-// ' (Z-vct.( ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> I L( (cl .er- (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District� 4, h v u s......„ N v 6(t� <br /> Di This project is a new building or structure. U Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br />• SANITARY SERVICE: PERMIT NUMBER: U Rural Address <br /> FEWER tPTIC i 3 - z 11 - c /‘U (new/existing) <br /> HEIGHT IN FEET: i I" NUMBER OF STORIES: (Not including basement) <br /> I q / ❑ 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: 1 ST FLOOR: 1--, <br /> ErosionControl permit <br /> / , a 1 ^ 2-V �"s5`! 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: / 3RD FLOOR: / dll►ng/aCCeSS) <br /> Si 3 v <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ `, and available options. <br /> (Please round to nearest dollar) �QJ d e <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 MNo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Efres No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 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) [Yes ao ['Don't know <br /> 7. Is this to correct a violation? [Yes to <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -. <br /> 545-112(4/08) <br />