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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C +TOMER TO PROVIDE <br /> OWNER NAME <br /> T- PIP,. oti{ <br /> Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> c/70 /1,./Y / 7 Gv4 viv 4 A IA, i S 5? a ante(#riction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDR SS <br /> 60 g 5v .--/e, b( &of 33 y-CDa / S irtp i t° -'@-X1i-Fno• rC)�t Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION ` and includes dimensions <br /> AGENT NAME CONTRACTOR NAME V <br /> n ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ I e Plan oval from <br /> pli e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) Elevation of property <br /> PARENT PARCEL NUMBER: t� /� CURRENT ONING: ACREAGE: P P y <br /> 0 PARCEL NUMBER (5V©8^ CI 'gS5 1Q'�0 '� ( frontage drawn to scale. <br /> TOWNSHIP: SECTI ,� 1 ,,1 <br /> '`\ \\C f 1/a: /�1 �� '/at/a: /V E ❑ Driveway Its <br /> ADDRESS: (stat , ounty,town)CO q ? " . k 14 / ❑Sanit ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT private) <br /> IC <br /> "" p ) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> �A-C f f€c- c q pQ Sc/tFs�/ f <br /> A c f/ 014,6 LU 5 t.4 C W Zoning District <br /> . his 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 dress <br /> FIEWER raiEPTIC /4 (new/e 'sting <br /> t <br /> HEIGHT IN FEET: / / NUMBER OF STORI ES: (Not including basement) <br /> ❑ Wetland/Flo ain/ <br /> Shorela (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionContro rmit <br /> � ID j TOTAL SQUARE FOOTAGE: + (slopes,d' rbance, <br /> 2ND FLOOR: 3RD FLOOR: / (`'f�/h fIIIIngI C2SS) <br /> ❑ Review Location Sury <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) $ 1� a d 0 <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? [Yes Ero ❑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? [] es ❑N <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank' none) <br /> 6. Is a location survey required? (see reverse) Elves o ❑Don't know <br /> 1 7. Is this to correct a violation? Oyes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -1 -∎ <br /> 545-112(4/08) <br /> 1 <br />