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■ t <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ii Icl4AE- 3 Ln.i.r4 <br /> ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �� 2 Deed Restriction;CSM <br /> t(0Zc 0(0•441.- t'I(, S,4IL.. 1O'1 e Pt 118 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS I <br /> 44o-831-135'91 �nnich4 1 . 1 inn - ou4(Dok-.Gorr ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> MAIZIA KDVAciI ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> T.o.2,K °12 <br /> (City State,Zip) (City,State,Zip) Setbacks <br /> &Ir l ?A A I I E A Y T 5359.o <br /> PHONE PHONE El Site Plan approval from <br /> 5f 0309 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Maria Sim S ldfn .4-rors.cay 1 ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ❑NUMBER RC bo /oiso-c i-&155-7 'R -3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 'BLOOM I 14(J Gf2oJE 1/4: 1/a'/a: y Driveway permits <br /> ADDR SS: (state,county,town) <br /> 2S YOLO Ak tub <rn D1So� <(.i)1- 53-7 I1 <br /> • _',-iyl permits <br /> CSM: LOT BLOCK/LOT <br /> ( 9 (public/private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ,�, <br /> �eimoVe F1.AM RCOF 7 �GPCAC-G ' 1 TN TVIt-4 ROOF IS� Honing District <br /> • ['This project is a new building or structure. t Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ' •• - - <br /> REWER rEPTIC (ne existing) <br /> HEIGHT IN FEET <br /> qS1` S NUMBER OF STORIES: (Not including basement) <br /> 1 Wetlan• oodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ErosionControl permit <br /> `025 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: • `� <br /> D'4 `J \-..1 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ p 3 i �5 and available options.1-4 Please round to nearest dollar) Il <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yes I 4o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o Jon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yeslo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes IVo <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 ❑Igo ®Don't know <br /> 7. Is this to correct a violation? ❑Yes a. <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />