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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CU TOMER TO PROVIDE <br /> "�, a..4 Ge.Ne. F o,r\2y Ce, r -Sor C�.u�)....se l� R- <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ` �` 'C�v •`� ,���`` � Zoning Status; CUP; <br /> 1:22AR -Sgc\tW C se_ � .. V e-Co nD- WT- S3 1-z, Deed Restriction; CSM <br /> HOME PHONE LL PHONE (..Geis) / E-MAIL ADDRESS 1 /ariance(# ) <br /> Go' - 2)4. -$7z- 1.r1 j K 0 c 4-0.r\e. CtitCejr.Or ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION <br /> AGENT NAME nd includes dimensions <br /> CONTRACTOR NAME <br /> AGENT ADDRESS ite Plan including location <br /> CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE <br /> ❑Site Pla pproval from <br /> applic le township. <br /> E-MAIL ADDRESS E-MAiL ADDRESS <br /> ❑ loor ans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: • • - • CURRENT ZONING: ACREAGE: Elevation of property <br /> PARCEL OG 07-Z`f I'Qt p iT, f_4 A{ 4_7 frontage dr to scale.NUMBER <br /> TOWNSHIP: SECTION:)( , S <br /> ���''f\ / /, .1/41/4, <br /> ` <br /> t` x ❑Drivew permits <br /> (stat , count town) <br /> n)ADDRESS:229Ct Si),1-,!`u5 Qc5c, R q � rn \-11- 3 S Sanita permits CSM: LOT SUBDIVISION BL OT <br /> (publ' ,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: STAFF REVIEW <br /> \c..c e.tne+:C d c off--°_z— ' ^(.r`r <br /> . � � \v o�,�� oning District <br /> This project is a new building or structure. <br /> ❑This project is an addition/a ration to an existing building or structure. ermltted Use? <br /> SANITARY SERVICE: PERMIT NUMBER: /0 A es <br /> DEWER EPTIC ($ (new/e �Stlfl <br /> HEIGHT IN FEET: Go t7„ ..v)-\F'•• NUMBER OF STORIES: (Not including basement) <br /> \ocs.N2.., C's/ken,,\ cn.�rAs NI/I - ❑ Wetland/ odplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore d (attac ent) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ EfOSIOnCO OI permit <br /> ,, TOTAL SQUARE FOOTAGE: 4, (slopes, turbance, <br /> 2ND FLOOR: 3RD FLOOR: _ — ling/ ceSS) <br /> R <br /> ESTIMATED CONSTRUCTION COST: — Review Location Survey T V <br /> (Please round to nearest dollar) -+ -' ♦ $ \ 000 and available options. <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? oyes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres ❑No <br /> 4. Has there been a zoning permit issued for this property iri the past 5 years? Eyes ❑No <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) Ekes ElNo ['Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/09) (Continue on Back) -► -� -� <br />