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tONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ,---- <br /> , D <br /> � <br /> l) <br /> 1 IrQV ( S f k�l ,e V1 ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zip) l� pp �[/ Deed Restriction;CSM <br /> (Od Street, (�tt(/l e- , I'�I/ /i S3 57L Variance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS t <br /> .6%-717.71651 "}mi SJ( o''',901.041-(c"-I-1 laSite 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 <br /> 010i660�-610�—$5/Sa A ") C Ex) r3. 22 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 6 L6 A co,,,,h J 5 2-0-6-h 1/4: S E 1/41/4. ❑Driveway permits <br /> ADDRESS: � Q (state,county,town) <br /> ioate3 �e5+ 6l�,e v 1//(0und S PoW ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: i t <br /> Qesl / toy et 01/1A e ❑ 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 /> �:'_,�,�`�- _ (new/existing) <br /> Il�`�� <br /> HEI .-- -"ET: / U r R OF S *RIES: (No including basement) <br /> �'� y2 ❑ Wetland/FIOOdplain/ <br /> Shoreland (attachment) <br /> • , - - - QUARE F•• <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> I 1 ] (Z V ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 1 l / filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> i ( ,) 3 3 5-5- ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ ♦ ♦ 2S� 40 v and available options. <br /> (Please round to nearest dollar) / <br /> 430 -&3 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? lgYes alo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes Epo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ekes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes llo <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) Lives .lo ❑Don't know <br /> 7. Is this to correct a violation? ['Yes alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —r -+ <br /> 545-112(4/08) <br /> eWOH 6uIsJnN hays pOdaej pue 1981.1s uolleldwo3 NSel VN <br />■ <br />