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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> OWNER NAME <br /> 11- k- Ill A Y\ Zoning Status; CUP; <br /> OWNER RA ORES ( ber,Street,City,State,Zip) Deed Restriction; CSM <br /> l'- e�k r v e Nance(# _) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .'2L5-( cta UJIS Kl_ tY • . het. Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION an includes dimensions <br /> AGENT NAME CONTRACTOR NAME o <br /> AGENT ADDRESS CONTRACTOR u1 ` of well/septic <br /> uding location <br /> SAAt <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE ❑ ite Plan ap val from <br /> pp' ab ownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Fl or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: levation of property <br /> ❑NUMBER 051- Otoo7-Z54-$2.40.6 A - ( AO. / frontage drawn t ale. <br /> TOW SHIP: SEC 0 <br /> r,Y` d,��e �— 1/4: S R 1/41/4: k Iz- ❑ Drivewa ermits <br /> ADDRES (state ounty wn) <br /> IS.' \f vhigO� 94 - ❑Sanita ermits <br /> CSM: SUBDIVISION BLOCK/LOT <br /> 11 (pub' ,private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> I S :C P RIPTION: .--. ■ <br /> ��1�: . • — , ® nin District <br /> k�� 0.� ..._--- £A' .iLmn- avil�� 1 <br /> . This project is a new building or st`cture. r e *11 ❑ -ermitte Use <br /> ]This project is an addition/alteration to an existing building or structure. • <br /> SANITARY SERVICE: 7fEPTIC PERMIT NUMBER: ❑ R ral ddress <br /> FIEWER t ew/e tin <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> IS, 5 I etland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachme <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> /Soo j TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) ssi <br /> X00 � � <br /> ❑'Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ ®© / and available options. \,3 6(Please round to nearest dollar) 1 � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ViNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes ❑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? Wes ❑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) Lilies No ❑Don't know <br /> 7. Is this to correct a violation? Oyes ,No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -i <br /> 545-112(4/08) <br />