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ZONING PERMIT APPLICATION www.countyofdane.cofll SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ' 1?ei G lZde ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> $771 i MS /I)// SO vJ7.- ZO /9/ecXi - S-3SS Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br />} off"-4s--8- ,, G - . - i t. ,9/'/cn. C'.p Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION 7 and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> • <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.usn El Elevation of property <br /> PARENT PARCEL NUMBER: CU ENT ZONING: ACREAGE: <br /> ❑NUMBER 636/618)2 -2Q-922.o-0 h i (Ex) Z. 0 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Al G- T / ),, 1/4: ivy ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> s/ 74 Pi -S 't7d FD /"I 6ZSAJ92 C, <br /> ❑Sanitary permits <br /> CSM: 1 LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: L/ <br /> CC/lCS TD GC)(is,i,`'G Ho ufe- _J 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 [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> zo,./ ❑ 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 /> y TOTAL SQUARE FOOTAGE: + (slopes, disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> S0■2 FT ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: o <br /> (Please ♦ ♦ .♦ ♦ ♦ ♦ $ /p and available options. <br /> Please round to nearest dollar) p Cif, r�J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EziNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes EINo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 'VIYes 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) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EINo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4l0e) <br /> (Continue on Back) -0. -■ -i <br />