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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME C <br /> 3 A J )O1 A'`4 / Jet✓ . 6cAA42 L 6Zoning Status; CUP; <br /> OWNS ADDRESS umber,Street,City,St�t,�� Z^ip)! n p • _ Deed Restriction; CSM <br /> �� K g� NHS t.J( 5��S9 Vri,ance(# ) <br /> OA1E PHONE CELL PHONE E-MAIL Aq DRESS 6 1' <br /> F0' 51S•1510 S� �"`(fON 44r•;l,`2. coS - - 10ut.�` 4(4 e c'�`�""'GO Sit. Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION at'id includes dimensions <br /> AGENT N ME CONTRACTOR NAME <br /> J( _t )st u30 (4raAy. sit4te Plan including location <br /> AGRJ nTADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) etbacks �= <br /> MkStAiiit li3( <br /> PHONE PHONE ❑Site Plan approval from <br /> (1ggo _'?341 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ." <br /> 0 ir\ Out, ,Ic5�.,,;, l ..-A <br /> bFloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT NING: ACREAGE: vation of property' <br /> ❑PARCEL /� frontage drawd-tii scale. <br /> NUMBER 01 12 Zb q �9 . 0 '0 -' ( E1'-/C 3, <br /> TOWNSHIP: SEC O . -' <br /> J 7 ,/4_ �� ,%,A4. k J ❑ Driveway permits ��\ ? <br /> l —" (state,county,town <br /> ADDRESS: �r' <br /> ❑ Sanita ermits J.� J} 0 <br /> CSM: LOT SUBDIVISION BLOCK/LOT / � <br /> (134a1 , private) t/ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DE [I D ON: 0 �, N ( eq --S g <br /> c5 1\ {`1/ /Zonin District <br /> . ❑This pr .ect is a new building or structure. LJ Permitted Use? <br /> This project is an addition/alteration to an existing building or s ru ure. lk CO\(I <br /> SANITARY SERVICE: PERMIT NUMBER: A l ❑ Rural <br /> EWER TIC ! �/ (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �� klA <br /> � <br /> I "ii t 31 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) e <br /> BASEMENT: 1ST FLOOR: <br /> ErosionControl permit V L <br /> TOTAL SQUARE FOOTAGE: ♦ (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/aCCeSS) <br /> c) ( ��eac)�) t� <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ O © ,, / and available options. v' \- <br /> (Please round to nearest dollar) Q ©v <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑fris ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Pies ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies No7 <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) ❑Yes 14 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) <br />