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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ovvyfR NAME �� <br /> 1TLAbtA lo(.c.m) NIO -TA/0 !.(_7f,1/J<( .e. ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,CitState,Zip) ��ij�y��6 L Deed Restriction; CSM <br /> HOME 5 PHONE atir'CELL PHONE S E-MAIL ADDRESS � td s3 s36-456? Variance(# ) <br /> 60 '8 °:''/3OeO:— ? 5 <8(;G cy v iir� v" ztt J 1/J'/ t75 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 77r71o77/IK (e<kalt) iijzo6 COIV 7 UCTWD/IJ/ 4i. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> O X s rIV E A p E1� D S777/0¢ 4,6 <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> DG`ON, GL's 3-375 DlLfLGON, 575 ❑ Site Plan approval from <br /> 6o6 — 4'45 _/ ‘130 - 1/55" - /3430 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> R/n 41 Al _i/O- ''Ctro/t1) ,4,471oo, co ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NU ER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL �`� �e//1-//,,,g�r E3 ` g frontage drawn to scale. <br /> NUMBER �7 iY (../- <br /> TO SHIP: SECTION: <br /> X j7 A.1-Q r0 '/4: %IA: ❑ Driveway permits <br /> ADDRESS: n A / (state, county, town) <br /> 65' -2- iZ / 51 t U6t'[1O/U� r s-33.99' ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> %DL,-9,05-;H/p 5,9.4.-r- /A6. ❑ Zoning District <br /> . CgThis 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 I EPTIC A- (new/existing) <br /> HEIGHT IN FEET NUMBER O TORIES: (Not including basement) <br /> ? / / Li Wetland/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: 1 ST FLOOR: 1-1 <br /> ErosionControl permit fir 4. TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 000 filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 020©© ' ' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: —N. —P. --0. ♦ —0. --► 305 ' 2 `D,O and available options. <br /> (Please round to nearest dollar) i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ®No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes p.m ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? g'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 'lo <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 ❑No ['Don't know <br /> 7. Is this to correct a violation? [Yes a10 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -* <br /> 545-112(4/08) <br />