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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> 014Q.ER NAMkl. <br /> S \\ <br /> � eVe oning Status; CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zip) ee Restriction; CSM <br /> 1 I ( .;, ��,, cif a,`, i 5��» ar' nce(# ) <br /> HOME PHONE LL PHONE E-MAIL ADDR SS t <br /> %5 t 6�)6 � ,` v ° t ``��` - k' ! r ❑ Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION a d i cludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Sit Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of ell/septic <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE ❑ Si Plan proval from <br /> a pli le 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: CURRENT ZONI G: ACREAGE: p p y <br /> ❑NUMBER cY P 1�1 V 67 7 '�.,, , frontage drawn scale. <br /> TOWN HIP: SECTION: ` <br /> �CU V 1 1/4: S W 1/411/4: ❑ Drivew permits <br /> ADDRESS: ` CC�� (s e, county,town) <br /> CSM: I ' ! �:c �\ LOT \ ,. SUBDIVISION 1�, 1 BLOCK/LOT' ❑Sanita •ermits <br /> 416 SP alb. (p • c, private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT CRIPTION: . ` <br /> �`ju-11 kA\n'.tc- G. .-?4,CI • Z ning District <br /> . IZThis project is a new building or structure. ] Permitted Use? <br /> ❑This project is an addition teration to an existing building or structure <br /> SANITARY SERVICE: PERMIT NUMBER: Rural dress) <br /> FIEWER EPTIC (new/e . <br /> HEIGHT IN FEET: 4 ic:3 NUMBER OF ST9RIES: (Not i cluding basement) <br /> f f ❑ etland/ odplain/ <br /> or nd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) rosionCOntrol permit <br /> BASEMENT: 1ST FLOOR: `) <br /> TOTAL SQUARE FOOTAGE: 1 ( lopes, disturbance, <br /> !ling/access) <br /> 2ND FLOOR: 3RD FLOOR: &?Ci <br /> 54'Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ � f 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? [Yes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes -1§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? DYes ❑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 EDon't know <br /> 7. Is this to correct a violation? [Yes No <br /> '''N ^ r APPLICATION MUST BE SIGNED <br /> ^JlC (Continue on Back) <br /> 1 545-112(4/08) <br />