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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 4 / .(..,. <br /> L /I <br /> OW ERADDRESS (Number,Street,City,State,Zip) ❑Zoning Status; CUP; <br /> Deed Restriction; CSM <br /> 75--5-- / ii/'vec,71-- /N L6157- Ti`rt 5--35r.?z Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> OT-5YZ-.^26 V ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTO NAME <br /> v^---L 5 1,-"7" f_./- ❑ 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-MAILADDRESS E-MAIL ADDRESS <br /> ❑ 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 /> ❑NUMBER 6510 -07 i 3—' a-! • , iy Ty <br /> frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> I� 1/4: ,/4,/4. ❑ Driveway permits <br /> ADDRESS: tit/ r` (state, county,town) <br /> 4 Z5-3— /4/-et rte/ /N 7 rs�, <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> / / ePerc j (public, private) <br /> PROPOSED PROJECT INFORMATION L- STAFF REVIEW <br /> PROJECT DESCRIPTIO I: <br /> rW irr,>4 Pi r 4 /o4/ PO/-6-"A r ❑ Zoning District <br /> . FA This roject is a new building or structure. ❑ Permitted Use? <br /> is 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: �t NUMBER OF STORIES: (Not including basement) <br /> /3. e T ❑ 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) I—, ErosionControl permit <br /> BASEMENT: 1ST FLOOR?U I TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> ♦ filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> / �� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ 5-lj�G, ` <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes K]No EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes allo ❑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 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 I]No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -♦ <br /> 545-11214/081 <br />