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ZONING PERMIT APPLICATION www.countyofdane.com Ezrzar==c7 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ' I ,� J , <br /> r L O" # 5 ' w` )4 "J <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Numb r,Street,City,State,Zip) Deed Restriction;CSM <br /> Li 4407 lir/4.5 Variance(# ) <br /> HOME PHONE CELL PHO E E-MAIL ADDRESS f <br /> ,6193 Dio 3 • d: A_A.�r', ,'°Vvii . - ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / <br /> Sw�. fa'6-ems— (c3�v'M,A-.✓ lgt'/(� / ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> yqo714/4c Al-a <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE 6 " (S e a <br /> PHONE ❑Site Plan approval from <br /> COF-4') ' j'/o,3 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL ( , frontage drawn to scale. <br /> NUMBER �I I� o�2-q971-5 f�-2 2 J 'Z,3 d\C_- g <br /> TOWNSHIP: SECTION: <br /> 4-f A5� G a itt-- 7 1A: %I : ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> ill-to v IL-As taoPln_ ❑Sanitary permits <br /> CSM:,3 ` LOT . SUBDIVISION BLOCK/LOT <br /> �f7 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO ECTD CRIPTION: <br /> � i 1 i oil.) „ft bD Vt_ 6 ❑ Zoning District <br /> • ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> Wfhis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER IX6EPTIC (new/existing) <br /> HEIGHT IN FEET: `4' NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ _ <br /> - <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 1...i ErosionControl permit <br /> ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: `1 lie) 3RD FLOOR: filling/access) <br /> c_D e \ I LQ <br /> U Review Location Survey CONSTRUCTION COST: y <br /> (Please round to nearest dollar) —0. -11P. -+ ♦ —I. $ • r 60 and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes to lDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? , es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? III es Oslo <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) ❑YesVo ❑Don't know <br /> 7. Is this to correct a violation? i'es E3Vo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —+ <br />