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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Ki f'k cd `,, <br /> I34,11/1 gdASe ii1 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 70(Q 13 0wE.R,S oAD , 5-3508 Deed ce(#iction; CSM <br /> �,�-�c.>✓u��� �( variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> — ``��"" <br /> �i (BOO-5�°(a821 rhavIsef16Cv1Orus, 11Q, ErSite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGE AME C RACT)2 NAME <br /> 044 {1ats-� �ei-- <br /> Ste Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS Q C En ED <br /> of well/septic <br /> 7O6 Bt, 25 4(1 di <br /> (City,fi ,Zip), (City,State,Zip) Q Setbacks <br /> bial e r aL Of 53S-Q? MAR- 1. Q 7!r!- <br /> PHONE PHONE Site Plan approval from <br /> 60? -5 X' (,S 2 f I?ANF applicable township. <br /> E-MAIL ADDRESS �L E-MAILADDRESS C���IY��'1�:�i(i:i&flEVELUFR=" <br /> ✓' 014seti el/Was.ke'! i Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P p rty <br /> ❑PARCEL O5o7_ 2Z4(_61W-0 A /4 1 7, 46,O frontage drawn to scale. <br /> NUMBER ( �L -7 <br /> TOWNSHIP: SECTION: _ <br /> PIZls rose_, NG- %4: SE- wh: ❑Driveway permits <br /> ADDRESS: n n '1 (state, county,town) <br /> AS5DC'70 (0 1 o c,c .AIL S 1� g V i S 35o °o <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> 2 9 7 9 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: r ,, if <br /> 110 x(20 °C (2cckeJACOOT-N ❑ Zoning District <br /> . <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> DEWER LEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2:o v 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) <br /> BASEMENT: 1 ST FLOOR: ❑ ErosionControl permit <br /> ( ' x 20( I( 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 328 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: I 00 and available options. <br /> (Please round to nearest dollar) -0. "■ -, --0. '♦ ♦ S <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des EiNo UJon't know <br /> 2. Is there a wetland or floodplain on or near the property? S C eo .-w of p.rw1 ❑X Yes No ODon't know <br /> _ <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 in the past 5 years? Des ❑Vo <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) ❑Yes XNo don't know <br /> 7. Is this to correct a violation? Des X No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-119(4IfR\ <br />