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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> / a Eris � _) <br /> q '�'S/ � �.Zoning Status;CUP; � <br /> OWNER AD RESS umber,Street City,State,Zip) Deed Restriction;CSM <br /> 5"0(917 / Li e..*Cof lac-k 6a?f/-)Gv/ variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 1, 8'-07s 7-)1S 9g-.. 9-119y 2 r', :J/es'e fra/1S/20),f1Z C ' (-e?r Site Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME j a <br /> S21l-A.)hill( .�u.0 ci e,.,s 'flu)1 ii( !L itw -1 e r5 2 Site Plan including location <br /> AGENT ADDRESS COrIIRACTOR ADDRE S of well/septic <br /> 7�`/L/ Cti;ood fine'Tr 7''9Af card &-i-id Tr- <br /> (City, <br /> te,Zip) I (Ci State,Zip) �)/ �Setbacks <br /> ' SS 1)/6105 LU I Via& C%Y'S5 !"(a 71)5//)5 LC)1 535.2-g <br /> PHONE PHONE �']Site Plan approval from <br /> 60g--M E- 19630 6c,8-- 7R f- / -7 7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 56414_4;4 Le b u-cao/Pi s cc4 . 5e c.c.:f„../e/G„,/ „K- /u::,t«t]Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.ciane.wi.us/) Elevation of property <br /> PARCEL NUMBER: CURRENT ING: ACREAGE: p operty <br /> PARCEL OcVC'SO(, -3/�-sgtic-0 H" _l '- . 11 frontage drawn to scale. <br /> NUMBER h1 1 <br /> TOWNSHIP: SECTION: <br /> eia.L->/ r '/a: %Y.: Driveway permits <br /> ADDRESS: , tate,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits Q <br /> Cg 7/P 1 (public,private) Q.a--N 13 -,., <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Zoning District <br /> . ❑This project is a new building or structure. <br /> Permitted Use? <br /> NThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> EWER R EPTIC (new/existing) <br /> HEIGHT IN FEET: I NUMBER OF STORIES: (Not including basement) lid'Wetlard/Fioodplain/ <br /> AREA TO NEAREST SQUARE FOOT: t� Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 4-1-0 <br /> BASEMENT: 1ST ST FLOOR: ❑ ErosionControl permit <br /> 8 3 2. 41 O 3 Z 0 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> "�`� O filling/access) <br /> 2010 eeR;!. Gv rM� 3Rar-i:esR: 2zzI1/ j <br /> 56o dI ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST -� -► -�► and available options. <br /> (Please round to nearest dollar) /5.3)900 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yes 54No DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes LJVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [' Yes alo ? poo t <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 ®Jo QDon't know <br /> 7. Is this to correct a violation? [ Yes EgNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► • —► <br /> 545-112(4/08) <br />