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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER JIAME <br /> N()Cl-rt ._)Dtr A n ME i 1 Tai-2 <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS Number,Street,City,State,Zip) 5 Deed Restriction; CSM <br /> 4 • • k,0 5 a Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADLZRESS <br /> •+a+s-183i- •sl IQ- I - A a •., 01+ 1 i _ • 03.c. ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CQNTRACTOR NAME <br /> eJ I . ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRES of well/septic <br /> x}-183 12C-I) ()j <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE _ ❑Site Plan approval from <br /> 006-83) 1 sc� . applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Vvi. _• • .4a , 8 c i. c, •, ❑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 /> El PARCEL NUMBER J `MA 0-'3S — �.• P g LiC 1 Lc frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 1310Orn1 g Ceti 9--- 35. 1/4: 1/41/4: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: q <br /> 3 5 i vt`-ty- - Ly ❑Sanitary permits <br /> CSM: LOT SU:DIVISION BLOCK/LOT (public,private) <br /> Ili I 11 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> VeS OJECT DESCRIPTION <br /> to tUD wct\•Nc u-Th ❑ Zoning District <br /> ©This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: ■ NUMBER OF SIES: (Not including basement) <br /> ❑ Wetland/Floodplan/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1STFL00 <br /> tt 5eJ + TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> lJ..� tii����/// filling/access) <br /> 2ND FLOOR: 3RD FLOOR: �1 <br /> cLJ�/„ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ / 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 Po ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes MNo ❑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? DYes Ilo <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 ENO ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ —• <br />