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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> O NER NAME <br /> A.,✓tom �� U ❑ Zoning District <br /> O ERR ADDRESS (Nu er,Street City,S Zip <br /> �r -1n ciri Q,IAYc\kLl11 - all td r - ❑ Permitted Use? <br /> PHONE p E-MAIL ADDRESS <br /> (V. o • S ❑ Zoning Status;CUP; <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restriction;CSM <br /> AGENT NAME C• TRACTOR NAME <br /> a Variance(# ) <br /> -like _ ∎. C i■ _I tip I III ma din .I.. <br /> AGENT ADD' S CONTRACTORADDRES ❑ Site Plan drawn to scale <br /> Sl�, �"� ¶ I�' ' ��?` ! and includes dimensions <br /> State,Zip) (City,State,Zip) <br /> , Eta � �j <br /> lc, <br /> �' l� "�"` kk'\4 ❑ Site Plan including location <br /> �° (�� (c ( rte PH q4-PQ of well/septic <br /> E-MAIL ADDRESS E-MAI?tt)-ag -L ADDRESS <br /> Li� Setbacks <br /> 1 <br /> M. . M' a II /as_ . -..,1A i. I r S. 3) a 11A ' <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Site Plan approval from <br /> PARENT PARCEL NUMBER: ZONIN ACREAGE: <br /> ❑ PARCEL p�" applicable township. <br /> NUMBER 6'1)3 –)(P) --' D r` O <br /> TOWNSHIP: . <br /> — UX\ U G ur k('a I LP 1/a: ME 1/ : ij E. ❑ Rural Address <br /> DDRESS: (new/existing) <br /> 140 in cid 'L dd �I • V� .3 -` ❑ Floor plans to scale <br /> CSM: LOT <br /> SUBDIVISI• BLOCK/LOT <br /> ❑ Elevation of property <br /> PROPOSED PROJECT INFORMATION frontage drawn to scale. <br /> PROJE,T DESCRIPTION: <br /> _QQ t . Y, t i* S 1_,I.0„(&_r Lke 1 J ❑ Driveway permits <br /> This project is a new building or structur-. ; i' .�'Yui jt 4 (state,county,town) <br /> ❑This project is an addition/alteration to an existing building or structure° �Qd ❑ Sanitary permits <br /> SANITARY SERVICE: PERMIT NUMBER: (public,private) <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ❑ 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) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> TOTAL SQUARE FOOTAGE: ,, (slopes,p s,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ --► and available options. <br /> (Please round to nearest dollar) $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes W No ❑Don't know <br /> 2. There is a wetland or floodplain on or near the property? ❑Yes El No ❑Don't know <br /> 3. Have you talked with the township about your project? !l Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes ❑No <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? 'Yes ❑No ❑Don't know <br /> 7. Is this correcting a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> - <br /> 545-112 ttios> - (Continue on Back) - -÷ –► <br />