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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �y <br /> un 77,11.....„ <br /> .❑Zoning Status; CUP. <br /> OW ADDRE�S^(Number treet, ity,State ) � r Deed Restriction; CSM <br /> J �'/I i J Variance(# ) <br /> HOME PHONE CELL PHO E-MAIL ADDRESS <br /> /it ♦ �4 c [, / t b { J A 2 .1 9X + <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME P f btu 'C <br /> l ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE El 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.diane.wLusn ❑Elevation of property <br /> PARENT PARC NU BER: CURRENT ZONING: ACRE E: <br /> ❑NUMBER OM[ `13 j _3 frontage drawn to scale. <br /> TOWNSHIP: SECTI N: <br /> WO '/4: 1/a'/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:: .�' <br /> TO 7&S E- (p - (C tt'S oft( t�1Q/jS S ❑ Zoning District <br /> . ❑This project is a new building or structure. o biafi * � l4 ❑ Permitted Use <br /> his project is an addition/alteration to an existing building or tructure. 1 <br /> ANITARY SERVICE: PERMIT NUMBER. W��� ❑ Rural Address <br /> [)EWER [EPTIC 01.1 I (new/existing) <br /> HEIGHT IN FEET: NUMBER OF S 0 ES: (Not including basement) <br /> a t / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUAR OT: Shoreland (attachment) <br /> (Outside dime sions including unfinished area, ttached garages above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionControl permit . <br /> J 4, SQUARE FOOTAGE: y (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> .7 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: D and available options. <br /> (Please round to nearest dollar) -I. <br /> j c <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ❑No <br /> V] Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ❑No p Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ONo <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 igNo ElDon't know <br /> 7. Is this to correct a violation? yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />