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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OWNER NAME <br /> DE,VAJI 5 H US 7/\ p 0 z Ing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) eed Restriction; CSM <br /> 1t-1 I P P RTRZ. D6E HILV C OIZEGO&), WI( 5?S75 a .ance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> e08—%35— OSZ too - 35F-z957-- Ge-h fa., • &.l-iao. ca z-v <br /> to Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION nd• cludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ci¢-iwtE2DAl 4/6Z.,so/t/ CA-me-Row iv -50A✓ Si Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> I1- 17 kI/V64S I-YNA/PD 141 '7 kLNt7S LYNN kb <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> 5 T li 6 /1 70A4 w Xi 535 gq 57-0/)67/1 TOW I.JL, 535 <br /> PHONE PHONE ❑ ite Plana oval from <br /> Gong- 5/(D -3(455 loD$- Si(a - 31455 plica township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> c-tnelsovt Ib @Ya_hoos co GfhelSon lbe yahee2, can-v loorplanstoscale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) e Elevation of ro <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P <br /> ❑PARCEL frontage drawn scale. <br /> NUMBER 0SCa—b(23-3t52—$ Z-1 • b S <br /> TOWNSHIP: SEC <br /> iOwN OF 0 2E c,UA.) '/:.S +/4+/; ❑Drivewa ermits <br /> ADDRESS: (state un wn) <br /> 147 i PA R T Rs D6 E H ILL a2, OkE67oN IJ_, 535 7S ❑Sani permits <br /> CSM: LOT 1160 1'181 G 1 T7 (( 'BL•,i LOT pu c, private) <br /> 1 e P ) <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT q�S�RIPTi , <br /> (/ `7 ^(/` d rs c A D D I Ti oti ■ .oning District <br /> ['This project is a new buildin or structure. ❑ Permitted -? <br /> This project is an addition/ Iteration to an existing building or structure. <br /> NITARY SERVICE: PERMIT NUMBER: ❑ Rural ' <br /> EWER EPTIC (new/e 4 stirs <br /> HEIGHT IN FEET: i <br /> 1 NUMBER OF STORIES: (Not including basement) <br /> ONE ❑ VVoetland/F plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore) (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ Ero iOnC OI permit BASEMENT: 1ST FLOOR: <br /> Z G S j TOTAL SQUARE FOOTAGE: 1 ( ,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> J fi in access) <br /> Review Location Survey/4 0 <br /> ESTIMATED CONSTRUCTION COST: ♦ -4. and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ $ y s, 000 , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Do ❑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? ®Yeslo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes [i3No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank. none) <br /> 6. Is a location survey required? (see reverse) [Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes pplo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -+ -► <br /> 4 21 . _..3 . --). <br />