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I &— 037-1-Ko ilz 1i <br /> ZONING PERMIT APPLICA 10 www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / <br /> -- rIs Glv, La. ❑Zoning Status; CUP; <br /> OWNE ADDR�ES/S (Number,Street,City,State,Zip) � ' a, Deed Restriction; CSM <br /> Co Ce ( / V t oL d a c ��- 1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> GOB —ZOG-27f1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAM F CONTRACTOR NAME <br /> l ' 1, �j,..��CS ^7;K,i�r-ey ❑Site Plan including location <br /> A ENT ADDRESS COT CTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> r 0l , - _c7S -Co I 928 applicable township. <br /> E-MAIL ADDRESS , ADDRESS <br /> -tcµa,1 i 6,,_is @ 445 ,,t,�-- ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL r i 3 ,S1 GltrQl frontage drawn to scale. <br /> NUMBER O S-I(I -&At)-a <br /> TOWNSHIP: SECTION: <br /> 1414: ❑ Driveway permits <br /> �ocnQ- 1�: (state,county,town) <br /> ADDRESS: <br /> 6-'f 7 (.4,A, io,,,,_ 3SZ T ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> 905- <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 2.0 �J' ) ❑ Zoning District x <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 /> F1EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 0 c) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �O ��� and available Options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres No ['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? QYes ❑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 No ['Don't know <br /> 7. Is this to correct a violation? Elves QNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -. <br /> 545-112(4/08) <br />