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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #countyofdane.com t <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME I`1 <br /> 841#f d- /fl r.i SSA- &FTE D4AL 0 Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> .2S? c .TrvTE2/xkt., Deed Restriction;CSM <br /> Pi4SS Mr�mso,�, l,✓Z, S'3 7/p Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Ff-o/G S G2.l 910 97 0 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME pp CONTRACTOR NAME <br /> /1 n15e'n/ 1v1/hit 5 .Z.VC... /7/EA/c6it) dv,/e/tA4 z iC..- 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /pbAkfx $ Sv,lcA //O e,.4.4 s/: s4/ /g a <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> W,4vaiIFs4 G/. , Sarc - , NI. c-i ref <br /> PHONE PHONE ❑Site Plan approval from <br /> 00l FY, -V?34 fie,;-- iv f- /73 6 applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> hems EA' &doff,.s rvc,rvf T hew ceA, bv,fa/tx se_726./a/'r 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER CURRENT ZONING: ACREAGE: <br /> El PARCEL 0 70f /PI--9/ e7 /, S-0 2 <br /> frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /Pi tetel/ a/o$✓ 17 1/4: 5'k/ %IA: S k/ ❑Driveway permits <br /> ADDRESS: <br /> �OCC7 7 ;/_ -�- (state,county,town) <br /> 7 `v 4t ,,Q'./L ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> /2/2 3 L (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ali A./ s Al/£ gnM r/7 Du rt/f' -'i ❑ Zoning District <br /> r <br /> . 14 This project is a new building or structure. ❑ Permitted Use? <br /> 0This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER ❑ Rural Address <br /> f)EWER PEPTIC /3-d e/lY'-00,2 (K (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> c2 'G ., 2 ❑ Wetiand/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 /> / e? 7 Y.2.- 3 j TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, <br /> 2ND FLOOR 3RD FLOOR filling/access) <br /> 9 7)- G;-f 1— 0.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �p o0o and available options. <br /> (Please round to nearest dollar) ♦ --► ♦ ♦ i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Oyes ElNo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? Oyes j Jo ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? rC Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Oyes JC Jo <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) Oyes EgNo ODon't know <br /> 7. Is this to correct a violation? Oyes a10 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4ro8) <br />