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ZONING PERMIT APPLICATION www.countyofdane.com !===1:37 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER E �/ <br /> )C�A C) . .)--R i &, f/22- ❑ Zoning Status;CUP; <br /> OWNS A DRESS (Number,Street.City.State.Zip) <br /> /� Deed Restriction; CSM <br /> E /0 �6-ilikd 1')t 4 1/v TOO /7o/v/f/ 53:1 Variance(# ) <br /> HOME 'ONE CELL PHONE E-MAIL ADDRESS <br /> •d e , 7 £ ,Ai, .,', _it £"—S` 21 • - s lei. 01ZdOn i ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> L ❑ Site Plan including location <br /> AGENT ADDRE CONTRACTOR ADDRESS of well/septic <br /> (City,State.Zip) (City.State.Zip) ❑ ,Setbacks <br /> PHONE PHONE 2'E��te Yl naapprova ro <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJlaccessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL / 4 ' frontage drawn to scale. <br /> NUMBER ,o/_ 6/ ,. `." <br /> TOj,&810 IP: SECTION: <br /> 931s'- , . ❑ Driveway permits <br /> �`" S �' � (state,county,town) <br /> ADDRESS: n <br /> CSM. 6' DLO / b s-u6�1 ��� • s oc�vL53�3� ❑ Sanitary permits <br /> • (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> POli 4)/4 0/4,16 ❑ Zoning District <br /> . <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 /> J SEWER J SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 4 / ❑ 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: 1STFLOOR: ❑ ErosionControl permit <br /> �/ TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> �T� filling/access) <br /> 2ND FLOOR: 3R FLOOR: <br /> gal ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -11. -0. —, ♦ and available options. <br /> (Please round to nearest dollar) a iv,O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 4No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes /No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 2Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? gYes ❑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 ,4No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Ao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ♦ -9 <br /> 545-1I2(4:09) <br />