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ZONING PERMIT APPLICATION www.countyofdane.com (12:=1:=! <br /> PROPERTY OWNER INFORMATION C TOMER TO PROVIDE <br /> OWNER N <br /> I � s <br /> c� ti . t V ping Status; CUP; <br /> OW ER ADDRESS (Number,Street,City,State,Zip) �J <br /> ,�n eed Restriction; CSM <br /> I ' ` \2,•.0 6\1 t. -1,I l/■.) L•51,{,( ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ' .-ss6-061,0 •-, L- . -_ gr•. fa (- ❑Ste Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> A T NAME CONTRACTOR NAME <br /> )C3 _3-7t- i- (— ❑ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ ite Pla proval from <br /> 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/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of propert <br /> ❑PARCEL °CP'0 „ O/! _Q.41)7-0 R 'I ,I P frontage draw scale. <br /> NUMBER �C - Acs-e. <br /> TOWNSHIP: SEC N: <br /> '/a'/a: El Drivew permits <br /> A: N N <br /> ADDRESS: ‘ (stat , county,t <br /> V:;. ?t �-Q ' Kkog` � t��' 3-1i' t ❑Sanita ermits <br /> CSM: LOT I SUBDIVISION / BLOCK/ O <br /> (4&12.4(50 v iey J ./S� ipub private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> P CT DESCRIPTION ∎ ,l <br /> s Qew k� 5--k- , 2 oning District <br /> . <br /> This project is a new building or structure. ❑ Permitted ----? <br /> his project i an addition/. eration to an existing building or str cture. <br /> SANITARY SERVIC : PERMIT NUMBER: (� ❑ Rural 'ddre <br /> EWER ` ".O �v (neW/:xisting <br /> HEIGHT IN FEET: NUMBER OF STOR S: ( including basement) <br /> Wetland/F odplain/ <br /> Shore d (attachm ) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: /I ❑ EroSIOnCO of permit <br /> OA= ` V O l TOTAL SQUARE FOOTAGE: j (slopes ISturbance, <br /> 2ND FLOOR: 1 fillip access) <br /> t` gO ❑ Review Location Surve (MI <br /> ESTIMATED CONSTRUCTION COST: QG and available options. <br /> —10. —iii. -0,. -0.(Please round to nearest dollar) ©DC <br /> J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Flo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes -Pro ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? .,Wes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Peso <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 ,'io ❑Don't know <br /> 7. Is this to correct a violation? ❑Peso <br /> 545-112(4/08) S,3 <br /> APPLICATION MUST BE SIGNED <br /> �- (Continue on Back) <br />