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4 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> have d A. mid rat.tvie 6. Harris . <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Deed Status; <br /> 6450 Purcell Rota) Belleville, WI 53508 weed Re(#' Ion; CSM ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 608-848-1365 608-235-8115 liave tia rri s @#d s.net ❑ S'a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Si Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> I <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Plana rom <br /> a • e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) LI Elevation of ro e <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER 04 1/0614-341/-9242 3 g1-1-1 025-x_,) z.'167 ac v'Q s <br /> TOWNSHIP: SECTION: ❑ Driveway permits <br /> TO LAM D Verov10. 36 '/4: SE IRA: SW Drive, ay permits <br /> ADDRESS: <br /> 61150 Purcell led. <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> 0 8761 Lo+ Z (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> X <br /> Addite►, a view preimi It gazebo +o rroterty' I��'oc P oh gazebo' ❑ Zoning District <br /> • ®This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an additio /alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> rota I Nei jh-t- 13'10" I ❑ 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: r-, ErosionControl permit <br /> 102 S gate Feet j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> !02 Square Feet <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Plat and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ -'0. ♦ ♦ $ 5;500.00 (tax p <br /> 44 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? XYes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑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? ❑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 LI Don't know <br /> 7. Is this to correct a violation? ❑Yes IZI No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► ■ <br /> 545-112(4/08) <br />