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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OVVER NAME <br /> 4 fCr.'s)-ill Fju i �e, 0 Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City e,Zip) Deed Restriction;CSM <br /> L .q w,`,`crwi )I �jvivatilyr.r kit . S35"2_1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS / <br /> I5f' /fit/1- i 2ZO-0t 6,)k. ea-`� (44,N/c%,co0' 0 Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5 t Core. [Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 14315 4 coc(-�t,I- PA <br /> (City,State,Zip) (City,State,Zip) D Setbacks <br /> "nice c • 53100 <br /> PHONE PHONE 0 Site Plan approval from <br /> 60b1- 32e- 11'126 applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> N A ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: , ACR GE: 0 Elevation of property <br /> [PARCEL 0510 - 301 - ,t. --'t Z.4.4) 01-2. (,. 30( hc, s frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> (� <br /> I�.i 4\ar• 30 '/4: %1/4: 0 Driveway permits <br /> ADDRESS: (state,county,town) <br /> L �1 IN : y-,(`( R c� <br /> CSM: LOT SUBDIVISION BLOCK/LOT El(public, permits <br /> 3 591 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 11 cc <br /> rate nj it eC ❑ Zoning District <br /> NThis 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 /> EW A'h� <br /> ER EPT1C ," (new/existing) <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) <br /> 11 cs e V. - /4 i 4 O r.x ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: iv / 1ST FLOOR: <br /> !/ .2 a j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> // 3RD FLOOR: Jit 2 i filling/access)aCCess) <br /> 2ND FLOOR: <br /> A/l N/ L �o <br /> fill <br /> Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ O d © and available options. <br /> (Please round to nearest dollar) 07 ) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes ,lo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes o DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? es • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? []Yes 15rVo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 3Z 8( ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes Elio DDon't know <br /> 7. Is this to correct a violation? Dyes Vo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -P -P -P <br /> 545-112(4/08) <br />