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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME Q <br /> OWNER ADDRESS (N 2- <br /> ber Street,City,State,Zip) p) "oning Status; CUP; <br /> J ��Cr �lJ/ .5359) Deed Restriction; CSM <br /> J,2 5 /'J�'Y107ui Variance(# ) <br /> HOME PHONE CELL PHONE E-MAID DDRESS/ <br /> (p0; d JIe (SP pl.-- • •6trY ? Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> A NT NAME CONTR CTOR NA 'E/ /, <br /> Q p tS V f/k/v4 tt 1-� Site Plan including location <br /> A� T DRESS CONTRACTOR DDRESS of well/septic <br /> l3 4 /a� �� — 3 of/is /O .5�� <br /> (City, '.te,Zig) (City,State,Zip) Setbacks 25 <br /> i f . —i 1ti/ 5�S <br /> PHONE it PHONE Site Plan approval from 41 T <br /> Coot- '44'59633 applicable township. <br /> E-MAIL AD ES E-MAIL ADDRESS <br /> Qn,,i Pa';ar/ ?c r->-- 121loor plans to scale / /' <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ,}'Elevation of property //�F <br /> PARENT PARCEL NUMBER: CURRENT ZONING: _ ACREAGE: v p p y <br /> PARCEL ;,O;b©�c? 34-0 /J _ ' , `-2q1 frontage drawn to scale. <br /> NUMBER ✓� r^ <br /> TOWNSHIP: , SECTIRr�I.-� �(, �1 <br /> • zk2_ %4: /J w %41/4: Driveway per <br /> ADDRESS: (state,county own) <br /> 6 y 2I - v 1 v, 5 0 it % Q Sanitary its <br /> CSM: LOT 4- SUBDIVISION BLOCK/LOT (publi privat <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: N )A-F CL.z carte— ) ,?oning District <br /> . This project is a new building or structure. Permitted Use? S <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: /,�/�/` ❑ I Address <br /> EWER EPTIC /5 — 'q'— V t"/ t -Xiang) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ,_ 6 " ■ We land/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: i •' '' 0 perm) <br /> f(.� Q 339 t4 ,, TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance <br /> V J <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: _— 17 5'7 <br /> I g 3 J ` ? Review Location Survey , ? <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ I f � and available options. <br /> Please round to nearest dollar) ''T A# il <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes laic DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? CXIYes D io ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes D Jo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dyes alo <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) Dyes 'lo ❑Don't know <br /> 7. Is this to correct a violation? Dyes 'lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />