Laserfiche WebLink
ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME t' <br /> 7�v £7'j ern 7,4on�so, El Zoning Status; CUP; <br /> OWNERADDRe�S (uu,fi�_r,Street,City,state,Zip).„...., Deed Restriction;CSM <br /> // Vine - 7 bun Pnijj ' WI 5555) Variance(# ) <br /> H.• E PH E •CELL PHONE / ADDRESS <br /> "05— -1 , r 7 cam. • -_ a bre 004 D Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT E C CTOR NAME <br /> //aj� Aid7tl /7/17 ,4J//�rk. ❑Site Plan including location <br /> AGEq �ss ,�„ i corl;RAC JSS ,E of well/septCaWa/ �! c� <br /> (City, at ,Zip) (City, a gyp) ❑Setbacks <br /> ar 'ha�/ �1U31g iar�lla// �VZ� j <br /> P / PHON l Site Plan approval from <br /> � —655---J/ 7 4' S- 3I/4/257 <br /> � applicable township. <br /> E-MAIL al/moil il a /jo - eem E-MAIL ADD e//j) Q /,Go� ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://-/faccessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONIN G: ACREAGE: / ❑Elevation of property <br /> rty <br /> PARCEL Z { e cr frontage drawn to scale. <br /> le.ElNUMBER 05)2 O /2o--9V� RA ` / <br /> TOWNSHIP i / SECTION: <br /> Medina '/4: WA: <br /> ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: / 64/ 6 Z <br /> CSM: � LOT SUBDIVISION BLOCK/LOT <br /> ❑Sanitary permits <br /> /// / (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DES IPTION: <br /> / e& 511241e F. /% home- [3 Zone District <br /> This project is a new b'Gilding or structure. Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Addr'ess <br /> EWER 12 yyrr EPTIC "(new/existing) <br /> HEIGHT IN FEET:j 9'/e, a NUMBER O,7STORIES: (Not including basement) <br /> LI Wetiartffloodpiaini <br /> - relan (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 /> 0',1=rQSionContml per <br /> 2,/ ? S/ + TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> / _ j <br /> 2ND FLOOR: 3RD FLOOR: � ��) <br /> 2 Z 0 Review t.ocation Survey <br /> ESTIMATED CONSTRUCTION COST: �,/ , ,�rJ available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ .2 /Z. 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eyes Zo Epon't know <br /> 2. Is there a wetland or floodplain on or near the property? II es o Eon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ► es LVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eyes 120o <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 0 o EiDon't know <br /> 7. Is this to correct a violation? ❑Yes rl o <br /> (i‘2 'V APPLICATION MUST BE SIGNED <br /> Cam}.-2 a (Continue on Back) —► -+ --4.Rd5-���/d/l1R1 f U <br />