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rnLo <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> -LLOQ 41(E n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip Deed Restriction; CSM <br /> 6X,5-- / J OZ-�-w&-b C-� 6 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> • � "5 gZ n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .b“.A.e0.1 C. LLS 73/1A. ( [ • s- [' Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 30 -> C*9?-E-a5 Oj 5i,'-- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> S Ct,ti RAO-.1 b'/ 5--,3 -90 <br /> PHONE PHONE ❑Site Plan approval from <br /> &3 .- '3 applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ha• Li: T' ,- ■ ' e„I..Sti( n 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`SD�jgLq!q•/^ar_D frontage drawn to scale. <br /> NUMBER l4� 54, <br /> TOWNSHIP: SECTION: t ❑ Driveway permits <br /> O 60 N © 1/4' /0 1/41/4. it (state, county,town) <br /> ADDRESS: ems;•' )/ Y 4- <br /> CSM: LOT SUBDIVISION BLOCK/LOT n Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: it <br /> 'ftS< ❑ Zoning District <br /> . 'ZThis 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 /> DEVVER FEPTIC J3_—AO ?"'- 0 3 3 (new/existing) <br /> HEIGHT IN FEET: NUMBER STORIES: (Not including basement) <br /> 04,�?C1,II ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: ShOreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> ,<f 9 g0� j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> s C� filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> /10' 3 O / ' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ / � and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ( UU), Oc' r ,�o <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes FiI<lo nDon'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? I—]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) EYes ao ❑Don't know <br /> 7. Is this to correct a violation? nYes ,alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0' -i —+ <br /> 545-112(4/08) <br />