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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME n J <br /> GI�Cu'1-4-/R01911 No-2( ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> HOME <br /> SWONE RACE? ONE U'4 -O(E b1LWISS6 �� Variance(# ) <br /> 419 ?&O9+ .15&1 • •..R @• (Ylcu_-C-o-f fl ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ['Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) n Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) n Elevation of property <br /> PARENT PARCEL NUMBER: <br /> u c� CURR TZONIN : ACREAGE:,/ <br /> ❑NUMBER l/V 0 -V t 1^5�? I—Z -3A ./ frontage drawn to scale. <br /> TOWNSHIP: SEC ION: / <br /> 510 y 1"5 ei a Z 61 , 1/41/4: ❑ Driveway permits <br /> 1/4: <br /> ADDRESS: (state,county,town) <br /> 3« < C T Fl P El Sanitary permits <br /> CSM: I LOT SUBDIVISION BLOCKLOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION. �(��(- 1 <br /> ExdeM '3t& Wall tD C1Ce o c iGurs L ni T. ❑ Zoning 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: ❑ Rural Address <br /> EWER f EPTIC �— (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> -� ❑ 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) <br /> BASEMENT: 1ST FLOOR: EfOSIOnCOntrOl permit <br /> TOTAL SQUARE FOOTAGE: j (slopes, disturbance, <br /> f <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -� ♦ ♦ ♦ �� and available options. <br /> (Please round to nearest dollar) l <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eves INo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ENo ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ElYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes a <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 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EN <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />