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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 0 4 11 f 11 gtq✓'e •9►�t,i/-� P v ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> I39 t Kjcienvilk, -4iit 24 vc'/one( %I/J. 53993 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Go-335'- 9if{ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> N./4- Pooh,Sits ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS A II* wT• of well/septic <br /> Pc#0,1 49(-/1004ello S4. l.e' 5-39q9 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> ti.14 )/ W1. f394ci <br /> PHONE PHONE ❑Site Plan approval from <br /> 66y —Ho? — 30 9cl applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS El Floor plans to scale <br /> r 1/4 e d4 lI ,./ i ,cvIS, tern <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZO G: ACREAGE: <br /> ❑PARCEL 0607- 0ZZ(1312! o cr �, frontage drawn to scale. <br /> NUMBER W J <br /> TOWNSHIP: SECTION: <br /> spit,' 4q k_ 1/4: 1/a1/a: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> g399 KIed>rntf'II<_-R►'1e Ail d /0,44 ►VI .53 c I ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> aro 'z6 3 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Z 6)0 01 j n5(oLnd Sw%I"I rn i41 PO ii trZoning District <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: / �RuraI Addrees <br /> FIEWER g/EPTIC ✓ (neW xlStln <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) —,/ <br /> 0 lJ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: ;1` , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) J ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: 1 (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 2"Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q� r G/ OPO a a and available options. <br /> (Please round to nearest dollar) ♦ —0 ♦ ♦ ♦ ♦ $ r a <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 [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? ❑Yes 'YINo <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) ❑Yes ItNo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes [j]No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />