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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU-TOMER TO PROVIDE <br /> OWN R NAME (' <br /> i Y1 <br /> CAA-' S GL c e Ce r Y1 Zo ' g Status;CUP; <br /> OWNER ADDRESS (Number,Street,,City,State,Zip) D ed Restriction; CSM <br /> 3 as" K41.4- IL, Love S - PI-&■S 'e (..ti 1 53S q0 ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6o$-o(-9W C og-zoto- *097 M s C1-taef i Conn Sit Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION a d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Sckme a f�� Q P i Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Site P n a royal from <br /> pl. a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Fl or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ❑PARCEL o C/i I( _3 03_q(1i,� _?, A--1 11 frontage drawn Cale. <br /> NUMBER ll <br /> TOWNSHIP: SECTION: <br /> t(`'S\-0\ Qj _ '/4: 5-\JJ '/'/4: SE ❑Drive permits <br /> ADDRESS: (s e,county, ► n) <br /> 3ia5" k��it I dc, Lin. Sun Pra;rt.k-e GUI 53S-90 ❑Sanita •ermits <br /> CSM: LOT l SUBDIVISION BLOCK/LOT (pu Ali ,private) <br /> y r,s�( Gam►) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: 1 <br /> POD( #43 vse ISLe (i.•r x • /•ning District <br /> . ®This project is a new building or structure. ❑ Permitted e. <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: �� ❑ Rural dreS <br /> EWER DoEPTIC [///\`J (new/e 'sting <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1-L. i ❑ Wetland/FI plain/ <br /> Shore! (attach nt) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionCo of permit <br /> BASEMENT: 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: 4, (Slopes, sturbance, <br /> 3 a filling ess) ■ <br /> 2ND FLOOR: 3RD FLOOR: <br /> S�7 ,2o <br /> ❑ Review Location Survey 0 <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> —to.round to nearest dollar) I V I 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dees EINo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? O n es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? D es ❑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) DYes j,No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ETINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(4/08) <br />