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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 /> Z--/NL t /t' J ' a z= ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number Street,City,State,Zip) Deed Restriction; CSM <br /> hi / 1 141-4/F-K5 A/6— /1//ft/50A/ -53 7/ % 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 /> T� -7 <br /> �'J k-APP /DI✓y be i 'p /p <br /> �e z,)Cu,,,,6 f t%ec-rS,IC Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> R, -- At /1,'bvflze ,FGij) Sv,7t 21 oZ . N", '.L e /,-f 6--,7t 29 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Ma.rLVog, , w I 53-)QS 71,(,-et r so>^ (.j 1 53 7 OS <br /> PHONE PHONE ❑Site Plan approval from <br /> 609 — 3.S-- 0982- 608-a 3 s- ei 6 Z applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> yam,,. e-kh lyzi_p l/ - , L"-N --4.v n Q -6),.. IV-ex...toe I lc, C4 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL -'l 0 -0 Si -320 5_/ <br /> frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: TO7AM/or SECTION: <br /> 0. 1/4: 1/41/x: ❑ Driveway permits <br /> T°`"` °`� g�°`�"" ``S '� (state,county,town) <br /> ADDRESS: <br /> Li/ I 04- v5 /g-r---e— N(ce,b,5t2-1-, 5.3 7/ Z-/ <br /> CSM: LOT SUBDIVISION I� BLOCK/LOT ❑Sanitary permits <br /> /9 6-„,,, r kt- (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Def<- ❑ Zoning District <br /> . 11 This project is a new building or structure. <br /> ❑ Permitted Use? <br /> A , his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ER {EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> C t r S -C k ❑ WetlandlFloodpiain/ <br /> AREA TO NEAREST SQUARE FOOT: ShOreland (attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) © ErOSIO11GOntrOl permit <br /> BASEMENT: 1ST FLOOR: <br /> /�� j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> / s <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ' 60 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -01. ♦ ♦ -0. and available options. <br /> (Please round to nearest dollar) $ / d <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 6o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Flo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Eres ❑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) Ekes ErI ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes _ Ncr <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i ■ -i <br /> 545-112(4/08) <br />