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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 /> f 6 J(f &0ad) T V) ❑ Zoning Stat ; P; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) .I Dee striction;CSM <br /> 7 L 71 Pr; v 1 fRo(/5e4.�1 cif// WI- 03563 ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL A DRESS <br /> 1.0 -6`f3- -Oy01 6065 370-zg 77 StP V VI . 256 gh -f m4;i"COn\ Si Plan drawn to scale <br /> AGENT INFORMATION j CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS C TRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approv <br /> nship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL,NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> PARCEL Oketo„,VO73" ND_ i , I r x , !�( frontage drawn to scale. <br /> NUMBER 0� J� L 1 w <br /> TOWNSHIP: SECTION: <br /> RD/b 7 'A: SyN) 1/'/4: ,s E ❑ Drive permits <br /> ADDRESS: ( te,county,town) <br /> 7'`1 7 / Pr i vc-+ J Sat,k 6; W Z , 535 3 ❑ Sanitary p s <br /> CSM: B z5- LOT cp.. SUBDIVISION BLOCK/LOT ( U private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 1 C/ <br /> 6-g,/C ,0 Qv;I. o� 1 x 3 0 14 oning District <br /> 'aThis project is a new building or structure. ly Permitted Use? <br /> ❑This project is an addition Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Ad, <br /> CI SEWER SEPTIC (new/- istin• <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> / Z r+ 1 ❑ Wetland/F lain/ <br /> Sh nd (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: ❑ ErosionCon ermit <br /> 720 51'T 4, TOTAL SQUARE FOOTAGE: j (slopes sturbance, <br /> 2ND FLOOR 3RD FLOOR: <br /> filli access) <br /> 7 z.0srr <br /> ❑ Review Lo ' n Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ --► ♦ ♦ ♦ /; g0 and ava. a options. <br /> Please round to nearest dollar) � 000• <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 2(No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? L Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes allo <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) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'No <br /> /1 <br /> 545-112(4/08) <br /> `'� APPLICATION MUST BE SIGNED <br /> '0 , I , (Continue on Back) -► <br />