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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU,TOMER TO PROVIDE <br /> OWNER NAME J14 � �� a <br /> Ed / CV i A/ Zoning Status; CUP; <br /> OWNER DDRESS (Number/,Stceet,City,State,Zip) � pp C n eed Restriction; CSM <br /> 7 ( � C 4". /)'4, via '�a Variance(# ) <br /> eME PHO �ELIL PHONE E-MAIL ADDRESS <br /> • .g • 4 1,141 ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME C IRA R` 'E I <br /> e'�( v- Gm.vst• ite Plan including location <br /> AGENT ADDRESS ONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Site Plan proval from <br /> applic le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: (r� CURRENT ZON G: ACRE E: frlevatlon of property <br /> ❑PARCEL ©rrO/O '' / Q3'' 9\00.°)' R -/ age drawn <br /> I . <br /> NUMBER <br /> TOWNSHIP: SECTIO • . <br /> Un n r )"(� 1/4. 1/41/4, �'� Drive permits <br /> ADDRESS: {��- ( e, county,town) <br /> �• 7 9 K Er) 'R� 1 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> /J©� (•ublic, private) `_, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ' 1 t <br /> �0 h\ I • i Ill ®n <br /> �� a O oning District <br /> . ['This project is a new building or structure. / <br /> Permitted U <br /> This project is an addition/alteration to an existing building or struc ure. <br /> SANITARY SERVICE: PERMIT NUMBER: " C3 Rural .•reS <br /> FIEWER KEPTIC It'' Z,C` U (new/=,isting <br /> HEIGHT IN FEET: 1 NUMBER OF ST aNir,..-ment) <br /> ❑ Wetland/Floodp • <br /> Shoreland chment) <br /> AREA TO NEAREST SQUARE F OT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionControl rmit <br /> BASEMENT: .s1 1ST FLOOR: ' 1 ^ / <br /> Lj/ 4, TOTAL SQUARE FOOTAGE: l (Slopes,tjlS once, <br /> 2ND FLOOR: 3RD FLOOR: filling/a SS) <br /> ISM ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) "♦ ♦ ♦ ♦ ♦ ♦ !O S O 0 O <br /> r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ErNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeslo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? p es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 1211O <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 QI'o ['Don't know <br /> 7. Is this to correct a violation? ❑Yes [c.]No <br /> I `O ' �_ <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -p -i <br /> 545-112(4/08) <br />