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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 /> r <br /> Ohre cA1cr g e a / ( S� @-,:`" 6e j) l�1- ❑Zoning Status; CUP; <br /> OWNERADDRES (Number,Street,City,State Zip) <br /> Ce q Deed Restriction; CSM <br /> 1 �^ =�'� �� C�^��u^ GJ.�� �3� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> JZ0-'7-1-gytg9 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAMES —5 CONTRACTOR NAME <br /> -e.'.'jCOLO AlAlt.---- 4.r ek-o— <br /> RA.r)Alp ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2 3 , Cl.,-rs A."-- LI-2 3 cl-44 Z, <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> iltAtt I� t-0T S 713 1 .0 D‘= ,-/t'-1-e" <br /> PHONE PHONE ❑ Site Plan approval from <br /> (,o —P7 c-/ _ 7 GC Z applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL MBER: CURRENT ZONING: ACREAGE: <br /> ❑ S` l7�I )14 o) S <br /> frontage drawn to scale. <br /> NUMBER - 7, <br /> TOWNSHIP: Q SECTION: <br /> .�'"1.- A <br /> 'it 1/4. ,/4,/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> 5 Cp—7 I (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> re-- <41-4"9.A_- S • ❑ 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 /> EWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3 D -- -- I ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> L-( ,l TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: `-1 (^ filling/access)`-'3 8L( ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ 3 Z.2_, Gov <br /> SZ`b gz) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves no ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes ❑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) [Yes No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes III No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />