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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE • <br /> OWNER NAME,,yi j� '1 <br /> OWNER Gi—N �I PA )C" ' .R.5 VG01Y ' "4s-r Zoning Status;CUP; 4 <br /> /7/ 0� n J�) IV410�-r0N `,Vi 6-7351r C� Deed Restriction; CSM <br /> Q <(J Y j Variance(# ) <br /> HOM PHONE EL PHONE -MAIL Al3DRESS <br /> 628x. 71.3"4vc,7 O Si 3engon L rns n • ec.M `nj Site Plan drawn to scale A_g_ini AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions �I ,p <br /> AGENT NAME CONTRACTOR NAME_ t�Z ,"� J <br /> G /9/j f-1118l —ri pp Site ' '- luding location <br /> AGENT ADDRESS CONTRACTORIA/0615"ADppRESS of e l/septi <br /> I O71 VI l;W Orn 3' 2 S 2,/z),)//y <br /> (City.State,Zip) (City.State,Zip) C� ,Setbacks <br /> STordiC d I�i J`�3 51 / <br /> PHONE PHONE Site Plan approval from ,( <br /> 609 X73--8 c it, applicable township. /VA- <br /> E-MAIL ADDRESS E-MAIL ADDRESS , - <br /> IN Floor plans to scale i, , <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) / = Z <br /> PARENT PARCEL NUMBER: CURRENT ZONI/G: ACREAGE: Elevation of property <br /> /❑ UMBER o6rr 2.y3-5 e- --- .x <br /> ll 0 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> E4s9m- Sme iN'65 - the S K.1 %1x4: E f Driveway •ermits <br /> ADDRESS: ry (State,(•� ?,town) <br /> 57dC G rent f t 53St i X Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> r—__-___ �---- (public, •_"__ <br /> PROPOSED PROJECT INFORMATION / �+ may( STAFF REVIEW l <br /> PROJECIDESC�/1.1 P T, / /FJ I X !gyp / x /D 4- S J��• /J3•J Zoning District A / <br /> ['This project is a ne • ' sing or structure. �--� �Permitted Use? A 1 A h <br /> This project is . addi'i•- alteration to an existing building or structure. �^4 <br /> SANITARY SERVICE: PERMIT NUMBER: IhRural Address t' <br /> EWER LEPTIC ailr xisting) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 1 Az Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) fy�q{ <br /> BASEMENT 1ST FLOOR 3a.ErosionControl permit <br /> a j, TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, A///,g- <br /> 1 <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 9 c IV Review Location Survey AjA <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. i AT <br /> (Please round to nearest dollar) $ 13, 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ENo <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) Efres M: o DDon't know <br /> 7. Is this to correct a violation? ❑ es o <br /> APPLICATION MUST BE SIGNED <br /> 645112(MOB) <br /> (Continue on Back) -* -O <br />