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r <br /> it <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Je FF A nd R,eheCa cil V V&, l [Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> I I 00 ti R-0f +✓d�e✓'�DVI > 'v1 S3 S3t-( Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS �'Sl//ck, e0 L7 Ql],(I <br /> b( 'begs !0N1 (obf�bci 40 L Y. ' G7 / �9 ail, [i]Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> []Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 121loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑PARCEL 60512-11 g 7 g H 1 —Z s frontage drawn to scale. <br /> NUMBER /// �T <br /> TOWNSHIP: SECTION: <br /> T I W n o lb( 6 n '/a: %a'/a: ❑Driveway permits <br /> ADDRESS: _ (state,county,town)"-{v1. <br /> 116 0 Co urr1j -I-f i h way A E d gerion Wl S L <br /> CSM: LOT SUBDIVISION J BLOCK/LOT <br /> ❑Sanitary permits <br /> C SM U ,i CM I _ (public,private) Iti A <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> r o.s --carne- out►I d i n/ 1/d/-4p\ ❑ Zoning District <br /> . OThis 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 /> EWER 1)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> v' I Ft I ❑ We tland/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: I W 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> 3q x 14 s-pr j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: I 3RD FLOOR: n I^ �� <br /> 1 l 1�+ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ j D� ,�,m and available options. <br /> (Please round to nearest dollar) t (.� i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 'lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ,I3Yes EliVo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes OVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes jRiVo <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 02 o ODon't know <br /> 7. Is this to correct a violation? ❑Yes 'a o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(a/os) (Continue on Back) —► —► —► <br />