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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> f e r <br /> ID Zoning Status;CUP; <br /> OWNER (N t,City,State.Zip) <br /> • Deed Restriction;CSM 3/ O a 14AI f ct/_ r d ccc,n e,-a.;r; ._ C.v� Variance(# <br /> )HOME PHONE CELL PHONE E-MAIL ADDRESS /S <br /> 3.$"C10 <br /> �� ! Y' é _ inc.,- .L�_ 0 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 'D ' F s i-c ,`11-A t-A L':'t Ri c j Sg.� s d p c,5 nj 0 Site Plan including location <br /> TRACTOR ADRE <br /> of well/septic <br /> La. 8i1 -d rd �1o / €'I- d� <br /> . <br /> (Cif Stale,Zip) ❑Setbacks <br /> PHONE 6-359 6 PHONE ❑Site Plan approval from <br /> Y t-Li q -L,j 7 q 7 60 is - cti f-`90 d applicable township. <br /> E-MAIL ADDRESS tt E-MAIL A DRESS <br /> • <br /> 401 • . 1"),ii ci:i. 'D iy'a, _ a,✓.vE,,• (.G, l;.�it4. ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ` <br /> PARENT PARCELNUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> PARCEL frontage drawn to scale. <br /> NUMBER Q t 0 ,(.'+i/ IC � A SY g <br /> TOWNSHIP:0�r-�j�,' �p��44L�o'�`.0 SECtIIO"N: <br /> ADDRESS: G rca:y �+5 O /0 14: ,s-L1 14.1/4: 51;,«J 0 Driveway permits <br /> RESS: (state,county,town) <br /> 3r q3 <br /> csM: LOT SUBtIVISION BLOCK/LOT`, ❑Sanitary permits <br /> .►C4 al.-4,‘,11 e- (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5h 1-1.1 5.-5n.) c'u6 4,1.+i s, +-,..) ❑ Zoning District <br /> • ['This project is a new building or structure. <br /> This project is an addition/alteration to an existing building or structure. ❑ Permitted Use? <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPT1C (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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: ,sr FLOOR: ❑ ErosionControl permit <br /> It TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 60 <br /> ESTIMATED CONSTRUCTION COST- <br /> and Location Survey <br /> (Please round to nearest dollar) '► -► -► -► ♦ -► �"` ey'] and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes 1J I[ d EiDon't know <br /> 2. Is there a wetland or floodplain on or near the property? []Yes Ei ]Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? De o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ElYers [3Vo <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) g know <br /> 7. Is this to correct a violation? [Yes <br /> APPLICATION MUST BE SIGNED <br /> 545-112('ice) (Continue on Back) -1 -► -4- <br />