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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0)144Eft NAME �, ; <br /> �G4500 e \ `�,�,lh 6 1"4'' oning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State Zip) <br /> Deed Restriction; CSM <br /> 11 DIA )S > \4 .elomtauf, tOL S? o Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 19M tjrf • I 'X `` wx..110 Site Plan drawn to scale <br /> AGENT INFORMATION C3NTRAC.TOR INFORMATION and i eludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of w eptic <br /> (City,State,Zip) (City,State,Zip) tbacks <br /> PHONE PHONE ❑Site Pla ...proval from <br /> appli;i.le •wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n ' oor s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) evation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> PARCEL p frontage drawn to scale. <br /> ❑NUMBER 0$©G 1 GI �Oz,CI \ - / .'e� ' c <br /> TOWNSHIP: SEC ION: <br /> 5 �/. IA: ❑ Drivew., permits <br /> ' J(st. c. nty,town)AD l E S: <br /> I 0 I q li-S W vsfy I f---I ❑Sanita •-rmits <br /> CSM: LOT SUBDIVISION BLOCK/LOT •ubli , private <br /> Nee. <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: [�'� r D ,�/� <br /> S 1' Pt 4( ,• w ige4I oc,✓h oning District <br /> . ❑This project is a new building or structure. P fitted Use? <br /> El This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: 'PERMIT NUMBER: ❑ Rural Address <br /> FIEWER PEPTIC (new" _ <br /> HEIGHT IN FEET: ` NUMBER OF STORIES: (Not including basement) <br /> ` ❑ We n lood ain/ <br /> Shorela ttachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FL�R: C3 Erosi••NCO •l permit <br /> ) .. CEr IF TOTAL SQUARE FOOTAGE: 4, (slopes sturbance, <br /> 2ND FLOOR: �j 3RD FLOOR: fills - a« =-S) <br /> U S . ..,'..eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ CC) and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ 50)wO, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres Po ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? rives ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves 21No <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) Efres ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes [iNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />