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ZONING PERMIT APPLICATION www.countyofdane.com 7:=1 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 0 . <br /> te., L:1 S y Tee ( ❑Zoning Status; CUP; <br /> OWNER AD1SRl -72DRESS (Number,Street,City,Sta ,Zip) 1:-.)„ ,., or.- <br /> Deed Restriction; CSM <br /> HOME PHONE <br /> CELL PHONEE-MAIL ADDR S � ���� Variance(# ) <br /> S <br /> /U — 92 I - 7 Z H'1 r - e f t- CL. t41.A Co' '.j, UZI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) n Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ONING: ACREAGE: ❑ Elevation of property <br /> ❑NUMBER ER 051 Z-- 16 Li " °300-/ KKK /Q, ,9 frontage drawn to scale. <br /> TOWNS•�/yp o SECTION: <br /> (_,f I I D A, 1/4. 1/4. EI Driveway permits <br /> ADDRESS: ( 73 /' 1 (state,county,town) <br /> 1112- J r c r t r &) E- -S15:3 ii ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION • <br /> STAFF REVIEW <br /> PROJECT DE .C.41PTIpNli <br /> I % <br /> G( , cy y0 s� '�i,,, C' 'i dr/1k/ Bnroilp g District <br /> . This project is a neW building or structure./ ❑ P rmitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER r)EPTIC (new/existing) <br /> HEIGHT�EE� I I NUMBER OF STORIES: (Not including basement) <br /> ' Cl Wetland/Floodplain! <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4 ° + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR. <br /> 0.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --s. ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within q00 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 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 ii.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? ❑`fes INNo <br /> 50 67 0 APPLICATION MUST BE SIGNED <br /> (c, <br /> Cy d p° (Continue on Back) -► -+ —r•REV(01,19) 3 6 6 0 a �/ <br /> zontgy <br />