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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 /> 3d d IRS <1 ' r�/7F T ❑Zoning Status; CUP; <br /> OWNERA DRESS (Numtfer,Street,City,State,Zip) Deed Restriction; CSM <br /> q°0 3 LL)/`LM.4,K3 D 2 .-. .S o‘ ro,//01 .�3.�6 7 Variance(# ) <br /> HOME PHONE CEL PHON E-MAIL ADDRES <br /> (p0B3)oZ©S-?`??'I Kcv.S-f-vrc k e S fie`+- ❑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/) 1=1 Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL ,/ ] p frontage drawn to scale. <br /> NUMBER dT p6.((-oZ?�"ie�(D-/ IP ®7Q <br /> TOWNSHIP: SECTION: <br /> 1 1)L t,4 S A I C rNG S '/4: 1/4/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> d35-4l 61urlrY f/4)Y / So t.s cert.i-f, (o9T. ..3s S cj ❑ Sanitary permits <br /> •CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3(=, aZ (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C3 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 /> FIEWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI 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: ❑ ErosionControl permit <br /> , ll 561 t T- ,, TOTAL SQUARE FOOTAGE: ,, (Slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: p <br /> v©Lf cep. FT.. ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ J� and available options. <br /> (Please round to nearest dollar) w • <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes BC ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves Era ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes Et‘ <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 EN ['Don't know <br /> 7. Is this to correct a violation? ❑Yes Elfdo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />