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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN Eta —---b Q /�� =P�iGe2 <br /> ffLL�11—���" �`� "'7J "' `1 Zoning Status; CUP; <br /> OWNER ADDRESS Number,Street,City,State,Zip.) Deed Restriction; CSM <br /> 5te,/3 n a,7 ./ec� V all J ` , la.,_„ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 1q! e, — • c( , �mai4 `- "u4,/101 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO TRACTOR NAM <br /> "4 V .e-Pt ( ,.t P,e4.- ,- � c,� Site Plan including location <br /> AGENT ADDRESS CONT CTOR ADDRESS �/ of well/septic � K <br /> i 3y /�/a-� �,' ( f" ik <br /> (City,State,Zip) (Ci ,State Zip) �etbacks Y <br /> J 353 a- v <br /> PHONE PHONE [ Site Plan approval from <br /> (2p f cr - j x/(03 applicable township. (5 <br /> M ADDRESS E-MAIL AD RE S /r <br /> (Z a dij s ,,, „ , //•t, S . 1"-v - obe o d 1 tme€44-, �a,�' .0 F oor 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 0Dc{ogo-71 ,4 7j/ /1-t �)z f/ • frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> f q '/4: SE- '/a'/a: s.6. Driveway permits <br /> (state,county,town) <br /> wn) <br /> A s: 3 � � !pe" e..40s R Sanitary permits <br /> CSM: LO a suBDlvls]o BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> - .;¢e-2.O-Crr-t 0- �----� ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> ®This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> L :EWER y SEPTIC (new/existing) <br /> HEIGHT N FEET: II NUMBER OF STORIES: Not including basement) <br /> I\Y� �3 g /l ❑ Wetland/Floodplain/ <br /> REA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outs] a dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 1 TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ` i e3�Q� <br /> 44 D ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. ♦ ♦ -+ "10 DD� and available options. <br /> (Please round to nearest dollar) <br /> 1. The propertyriawittnif300 feet of a stream or 1000 feet from a pond or lake? [Yes [ Jo ['Don't know <br /> 2. Is there a fktiand or floodplain on or near the property? ❑Yes ao ❑Don't know <br /> 3. Have you talked with the tow lip about your project and are they in agreement'? ®Yes OW <br /> 4. Has there been$ bning permit issued for this property in the past 5 years? ❑Yes ao <br /> 5. Is this project associated with a rezonne/ONvariance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required?-(,s e�reverse) Ekes llo ❑Don't know <br /> 7. Is this to,correttaviolation? Efres alo <br /> \0 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) ` /_Li( (Continue on Back) ♦ -► <br />