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4 67-1 <br /> I;O SUPPLEMENT to Web-A # <br /> ZONING PERMIT APPLICATION www.county fdane.com pp <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER ME /_ <br /> J��f ss wL ❑Zoning Status; CUP; <br /> OWNER ADD (Nur�trtCity,Sta Zip) Deed Restriction; CSM <br /> °L_ ©°2 SCe R Variance(# ) <br /> HOME PHONE CELL PHONE�1 �J, ` E-MAIL ADDRESS <br /> �5~2 '( —14,A. /L C , e �: i • 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) ❑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/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑PARCEL /) frontage drawn to scale. <br /> NUMBER V� ©5/0-.`/7 o/--e <br /> TOWNSHIP: 1 1 t SECTION: <br /> 119W 4 61 KZTI(To? , ,/4,/4: ❑ Driveway permits <br /> ADD Ess: Q 1 f (state, county,town) <br /> U "Q--'e K�=j k5 ' f? \ ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ 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 [)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> PI L LI Wetland/Floodplain! <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> f <br /> 2ND FLOOR: 3RD FLOOR: /y /�} • <br /> "LY 7U ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �]� 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? Elves to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Vo 1 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? s No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 1-7es ❑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) [Yes ❑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 />