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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE A E <br /> oC , bins <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> $S`�S d,,,+,}� 12c/ 5/�✓,C C+ ,+i 1 t tU �3 5-V3 Variance(# ) <br /> HOME PHONE CELL E E-MAIL ADDRESS <br /> (.4 - Li y 3 )- n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> NAME <br /> S 1-, d �� ❑Site Plan cuding location <br /> AGENT ADDRESS CON P4A6T�F D RES of well/septic <br /> c1G0 L tic,i-L, i2-/ <br /> (City,State,Zip) (City,State,Zip) 111 Setbacks <br /> 6 <br /> PHONE PHO E `� 5 ❑Site Plan approval from <br /> Log,_ 6. i3 — y6 3, applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0- k ,• d eU-YV� n 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 690 7 -10Y `F3-9 b-t i 0., <br /> TOW SHIP: SECTION: <br /> o l� ,/4: ,%,A: ❑ Driveway permits <br /> by r� (state, county,town) <br /> ADDRESS:G <br /> 0 S15 kiOrnv n0_ Qd_ <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> ys�a <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> y 5 eti5e c.1 po✓-rir, 6- L4{ .>l ,"t ❑ 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 /> FIEWER <br /> 11�� EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I6' / ❑ 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: _ <br /> ❑ ErosionControl permit <br /> ��(� q` 1 ' 1 TOTAL SQUARE FOOTAGE: 1 (slopes, disturbance, <br /> I / •t filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: JO and available options. <br /> (Please round to nearest dollar) -0. -0 -0 -0 -0 -0 $ 3d c,9 a"- <br /> , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes RiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0. ['Don't know <br /> 3. 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 gjNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 32 3 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes EINo ['Don't know <br /> 7. Is this to correct a violation? [Yes ONo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br /> S <br />