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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App s <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER IIAME <br /> 7 Orel d S C 4 v 1Q1""7 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Z <br /> 3 2 d LG 1 d Deed Restriction; CSM <br /> 1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 'CS7-'17/y7;Okd .7 ,11• u ( . i,f✓&' '- d' 7 ❑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/) Elevation of property <br /> ❑ <br /> PARENT O PARCEL/OiY -13� S G CURRENT p ZONING: ACREAGE: g <br /> PARCEL Y 3 J Q (` lO_ y frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTIO <br /> tr�� ��( 1/4: ti 1/41/4: S1 ❑ Driveway permits <br /> ADDRESS: • (state,county,town) <br /> Z o2 i0 1L4 L) ri /I'1ef� l�^ �Z <br /> 3 ❑Sanitary permits <br /> CSM/ 2 LOT SUBDIVISION BLOCK/LOT <br /> 3 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ae x/2 1r/C) 3 S,` S ,D J Zoning District <br /> . This project is a new building or structure. J Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> EWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /0 - 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: ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: j (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> /�� Review Location Survey <br /> ESTIMATED <br /> dollar)COST: � and available options. <br /> (Please round o nearest ♦ —O. -11. -11. -11. -11. $/ OO <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? Ekes ❑No ['Don't know <br /> I3. Have you talked with the township about your project and are they in agreement? [Yes ❑No <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) [Yes ❑No ❑Don't know <br /> I7. Is this to correct a violation? Lives ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />