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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 /> AJIC4I4J6-A S ki ZC 113( 'b ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction;CSM <br /> /U`/-3 ca) V gD AizciMAN/4 IA)I S 3 5-6 o Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 668-22c JSOS 6a-22S-/F05— Ngec-NQie NC 2_5 a 0/00,c_-04-1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑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-MAIL ADDRESS 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 /> ❑PARCEL �^ frontage drawn to scale. <br /> NUMBER 63y/J 04/06 -Zgj-b37U-U ZA- I 2.23 <br /> TOWNSHIP: SECTION: <br /> MAZvrIANit CrO7Al(2-06E) 27 1/4: /J6- 1/41/4: /JiA.l ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> /b4/3(o OLD Y RO M42 omA,v it, /,v) 5"3 Sb v <br /> CSM: LOT 'SUBDIVISION 'BLOCK/LOT ❑Sanitary permits <br /> /2Z 6,7 I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> GAR-A6 ❑ 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 /> EWER 1)EPTIC (new/existing) <br /> HEIGHT IN FEET: // NUMBER OF STORIES: (Not including basement) <br /> i4/ •/O / ❑ 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 /> BASEMENT 1ST FLOOR: ❑ ErosionControl permit <br /> r(3Z 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 3 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ is 4/0��L and available options. <br /> (Please round to nearest dollar) / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [ Vo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Flo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 year ...?? ®Yes ao <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ZO ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes al. ['Don't know <br /> 7. Is this to correct a violation? :Yes ac. <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ - <br /> 545-112(4/08) <br />