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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> W0..1-4 4" Uhcul 6a<((A q ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �J Deed Restriction;CSM <br /> lo 14.9A-1 aq Ko, KP Ma o Ina niP) W i S3S43 t) Variance(# ) <br /> HOME PHONE CM_PHONE E-MAIL ADDRESS <br /> bbg 313 - g SS 0 SC,Io 0.l l w e @ me r r . 6orr1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR S��0.W��f�-1t wR <br /> �� ' ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> NiAcA SC h Q.e 11) a. <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> LD CLC 1 IN t 5355 S <br /> PHONE PHONE ❑Site Plan approval from <br /> 60S 313- 0 g TD- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r a fl„A.ell ty0 20oo 0•maA,(431K❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.o ane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL `�s , Z q y_qq 30.0 �p7 / 1. l 1 frontage drawn to scale. <br /> NUMBER 0I o4 R.— 1 <br /> TOWNSHIP: A SECTION: <br /> <o kb uX a 2C '/: SE %v.: Sf ❑Driveway permits <br /> ADDR s: (state,county,town) <br /> 6b�/ kt,y toy-0,a goa Skuk NIA, W( 53583 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> 1 3 5$ 0 a.. <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: „V Q W h b IZ (,YlStvac* <br /> o f ❑ Zoning District <br /> . gThis 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 /> HEWER VEPTIC 12- 2014 - o o 0 9 (new/existing) <br /> HEIGHT IN FEET: 1 ,, NUMBER OF STORIES: (Not induding basement) <br /> Z, - b Ali I ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ETOSIOnConto, it <br /> BASEMENT: C.--I-C8 1ST FLOOR: <br /> d�V ` ! / <br /> 3 3 13 j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: O filling/access) <br /> 't'v .Jl!7� �f/ <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ -► ♦ ♦ $ J 3q q . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes [' Jo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o Jon't know <br /> ® <br /> 3. Have you talked with the township about your project and are they in agreement? Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ElNlo <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) E Yes alo [Don't know <br /> 7. Is this to correct a violation? ❑Yes (lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -► <br /> 545-112(aroe) <br />