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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /1 (� �l <br /> §"`� iCSit t ,VQr °T' lLilt4b� . CC1„1(7�'C— ❑Zoning Status; CUP; <br /> OWNER ADD S (Number, eet,City,State, ip) 1 Deed Restriction; <br /> j HOME PHONE 7R Olk cEtL ir\S ' E-MAIL) AI L WI 53559 Variance(# CSM ) <br /> E-MAIL ADDRESS ` <br /> ,,08.656- 4O& 1 335 Vf7 • • • • Poo ° mod\•corn ['Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> n l ['Site Plan including location <br /> AGE DRESS Z c 1 -6Q, p s j9CO AOr R I DD YE�SS I I9 0-tope <br /> of well/septic <br /> -.Q-fix a�o0, Po Bo 9609(90(C , <br /> (Ci ,State,Zip) ' ['Setbacks <br /> • MI 1 ►._ • ' _t. t , J • a. .. �. <br /> PHO - P 4.08.-q464 ONE 0 Site Plan approval from <br /> WI 7 70- 325 70© applicable township. <br /> E-MAIL ADfog- <br /> ESS E-MAILADDRESS <br /> • 2-p Ci -1'20► butkell ,,C. PI ['Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ∎ ING f ACREAGE: EI TOWNSHIP:®N MBER a g)p-a'.3--g-115--9 alp t 5j,17© frontage drawn tO SCale. <br /> SECTION: J <br /> ;.: '/4'/4; !o�- [' Driveway permits <br /> ADDRESS: 'p�I � I (state,county,town) 11 R <br /> CSM: 63'q O!OT Pc r" " v SUBDI 1 r6(1, BLOCK/LOT 6'5559 0 Sanitary permits N.i�, <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DEfR TION: <br /> 6 U i kid '(1QAltrh 511211, UAW rQi n 1 d &la 1010 ❑ Zoning District <br /> -This project is a new building or structure. (i ••,�•) <br /> ,a��a ,, ❑ Permitted Use? <br /> ['This project is an addition/alteration to an existing building or struc ure. Sli?�Zigp, <br /> SANITARY SERVICE: PERMIT NUMBER: �s ❑ Rural Address <br /> EWER FIEPTIC (new/existing) <br /> HEIG TIN EET. NUMBER OF STORIES: (Not induding basement) <br /> /CI i 4 i) -Peak 1cJgln� r ❑ Wetland/FloodplaiM <br /> AREA TO NEAREST SQUARE FOOT: �a )C 7a.X�p'L <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ,---, ErosionControl permit <br /> N A j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: O� <br /> filling/access) <br /> N It 1st A soa 4 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► ♦ ♦ /1.0 000 <br /> Wu and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 0Yes ®No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes o ['Don't know <br /> I <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? QYes Oslo <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) Elves ['No Don't know <br /> 7. Is this to correct a violation? OYes ao <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -i ■ -4. <br />