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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME _ <br /> I t-l= CL l 6 m Aiirl CLC_ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> / / Deed Restriction; CSM <br /> 207 A/K- ST (/�,P�iv k}, Gt// -Sr -3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> in5-2-12-2 , AP /Le c azc _ ' , .;i--. ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAM, �j CONTRACTOR NAME <br /> ►�/L_t_ -1 UEV /�pc _ ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Z-7 g/ /21 t!d <br /> (City,St)atep) (City,State,Zip) ❑Setbacks <br /> l/eiY�hav; /tea �21�l� <br /> PHONE PHONE ❑ Site Plan approval from <br /> cez:t1 c..e. - 2 /2--2-6,l 7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [' Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL �q/ / 9 /t-�Z (�/L 7 frontage drawn to scale. <br /> NUMBER 06„2/0(700 L-47-3-0Tc7( '6 /6, 05 �O <br /> TOWNSHIP: SECTION: <br /> VER7ai.i - Vs: ,/4,/4: ❑ Driveway permits <br /> ADDRESS: Rd 1/473M/4 / <br /> - (state, county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D RIPTION: ,! L <br /> 5C 79 (7/Q/V ❑ 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 /> ANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> FIEWER NFEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /6 1 0 7de ❑ 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 /> 7/76 j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> // 76 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 2.70 / 006 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IIINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ENo ['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) Ekes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) - <br /> 545-112(4/08) <br />