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A —7o zs <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> I, 1 fk_ <br /> OWNER A OR (Number,Street, ity,State,Zip) ❑ Zoning Stat CUP; <br /> /,Z(,, -7 ( L'; tc ic_ Pr s . 1iA tAjz Deed Re Iction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE <br /> E-MAIL ADDRESS " 4 ."' <br /> (eOES— 7 -5 cx;) (,OO- (p`,,5-1 1>.j- ,Fer,1- C_t _, a (64 C- 'D r qck n Site Pla raven to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and irVudes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> n Site PIa I location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/ iE <br /> (City,State,Zip) (City,State,Zip) ❑ Setba <br /> PHONE PHONE n Site Pl. .0kval from <br /> applic.i'. : tcOship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor placr to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> ❑ PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevatl•n • 1 ..erty <br /> PARCEL <br /> NUMBER 0%,/G(11-poi-6•660-y 0-y i E 1 3 3 (Q 5 fronta.,'d . r to scale. <br /> TOWNSHIP: SECTION: <br /> •2/ cts -,- *T‘,' )5 1/4: 1/a'/a: ❑ Drive :��ermits <br /> ADDRESS: // <br /> •2(c 7 ( �1 fc�� C S 1,0'. <br /> �.5�L Icrt ViJ.� (sta �L tY,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT n Sa It rmits <br /> (pl��?r�r p vate) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: STAFF REVIEW <br /> eC ❑ Zoning 1144t <br /> • his project is a new building or structure. <br /> ❑ Permitt se? <br /> n This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Addr ss <br /> nSEWER P.SEPTIC (new/ex. ) <br /> HEIGHT IN FEET: J NUMBER OF STORIES: (Not including basement) t/�tt��/// <br /> ❑ Wetland/Fk ., ,. ,in/ <br /> AREA TO NEAREST SQUARE FOOT: Shorela (.tt:chment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: Li Erosion rol permit <br /> 4 TOTAL SQUARE FOOTAGE: 1 (Slope , -i, fiance, <br /> 2ND FLOOR: 3RD FLOOR: .7—'1 filling access), <br /> °-70 ❑ Review ation Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ -► --► ♦ L - and avai able options. <br /> (Please round to nearest dollar) I2'-i 7 3--- <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Ellees ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes E.No n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eyes n 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) nYes EtNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EINo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) ■ —► —► <br />