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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN R N M <br /> 0� E .k... -€,(1•601A__, ❑Zoning Status; CUP; <br /> OW ER ADDRESS (Number,St eet,City,State,Zip) <br /> ��3 im8 r ,,/� /V7`4.it e� ; • Deed Restriction; CSM ) <br /> 7 I /v Variance # <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> r "1710 ['Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> El Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDR of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL �7 Ru^I 11 Q�-5 Iii frontage drawn to scale. <br /> NUMBER 0 /0C a3If °14 Is o `'1 J <br /> TOW SHIP: SECTION: <br /> of r•NO t %: -1/4%: ❑ Driveway permits <br /> ADDRESS�: <br /> °) �, (state, county,town) <br /> L')? ∎elM .--t r LI anitary permits <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT ai,i„ (S (public,private) ) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: I M n �p <br /> R-er^• la d e ! o.”g4'o Si-I<, rt"...a-4- e-Y&?'n1 S F I L3 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: PER I UMBER: ❑ Rural Address <br /> EWER IEPTIC �. O ri— 0%3�C (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI 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: 1--, ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -I. -i. -11. -I. -0. -► 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? Elves fNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [Yes ENO <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ['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) Dies ❑No ❑Don'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 />