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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME -I . i <br /> I <br /> OWNER ADDRESS (Number,Street,City ,Zip) ❑ Zoning Status; CUP; <br /> 3 315 ` �1 <br /> � � � Deed Restriction; CSM <br /> // Variance(# ) <br /> HOME PHONE A CELL PHONE E-MAIL ADETRESS <br /> i 93` ? 92 e ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR'INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR <br /> s), 7 ;- ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS - of well/septic <br /> ,3a q /) Va li 644A ' • <br /> (City,State,Zip) (city, te,Zip) ,, Setbacks <br /> 5 1„)I S 3.s-p. 7 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 8 7 3 - e 7 /LD applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL UMBER; CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 0 A ' /'O - 53-' S5- / 8-3 , 5 7? frontage drawn to scale. <br /> TOWNSHIP: ((( SECTION: <br /> Dyv�, ,,, 14: 1%1A: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: l <br /> • ❑ Zoning District <br /> Li This project is a new building or structure. • /�t^c-C Q R <br /> L] Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER LI SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ WeflandiFloodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore!and /�±±��h a,± <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2- i <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ ♦ �V p O and available options. <br /> (Please round to nearest dollar) 5 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ®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? k^3Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Li Yes Mii 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 0 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 0 No <br /> APPLICATION MUST BE SIGNED <br /> 545-11214/081 <br /> (Continue on Back) —► -9 -9 <br />