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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> G,\\ \t‘QQ\e,5 C^ Z <br /> owNE D R s (Nu sve t,City,st p) . c ji Zoning Status; CUP; <br /> I <br /> lair ifu I I 5Ui I /a1K@ W 1 S 5:370 <br /> Deed Restriction; CSM ��b <br /> " • c P E_ I E +�-- Variance(# )• <br /> AGENT INFORMATION CONTRACTOR INFORMATION ❑ Site Plan drawn to scale <br /> AGENT NAME and includes dimensions <br /> n CONTRACTOR NAME <br /> yle <br /> 14N e..c <br /> AGENT ADDRESS ❑Site Plan including location <br /> ul/ Vtll &men k `+ CONTRACTOR ADDRESS of well/septic <br /> (City.State.Zip) GG-� <br /> (City,State.Zip) 14 Setbacks <br /> MC/J! l, Vr. 5s To i <br /> PHONE <br /> PHONE Site Plan a <br /> �p� Si� 4$$ ❑ approval from <br /> E-MAIL ADDRESS <br /> applicable township. <br /> to kr1 toe ,,....,I. C� ,) E-MAIL ADDRESS <br /> (J� ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.usn <br /> ❑PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Ei Elevation of property <br /> PARCEL <br /> NUMBER OW Olk"635° C ii,gigq frontage drawn to scale. <br /> TOWNSHIP. SECTION: <br /> W"ASS 0r yel: 1 1 : Drivewa mi <br /> ADDRESS: /4/4' <br /> Cry b Cod de.( ek W (state count , own) <br /> �oreS S353 t, <br /> CSM• LOT SUBDIVISION }—BLOOWLOT ,. Sanitary permits <br /> \t363 <br /> (public tv <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: STAFF REVIEW <br /> C- S''Z-Ci Zoning District C— Z <br /> • This project is a new building or structure. /gG <br /> ®This project is an addition/alteration to an existing building or structure. Permitted Use? <br /> SANITARY SERVICE: -- <br /> • <br /> PERMIT NUMBER — RUral Ad; -ss <br /> EWER [EPTIC (new dilaDti <br /> HEIGHT IN FEET; NUMBER OF STORIES: (Not including basement) <br /> 13 ❑ 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 157 FLOOR' ❑ <br /> ErosionControl permit <br /> 6o j TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR 3RD FLOOR filling/access) <br /> (00 <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location Survey <br /> (Please round to nearest dollar) '� –► –► ♦ –► –► '7 8, oo and available options. <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? <br /> []Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? JYes No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# <br /> 6. Is a location survey required? (see reverse) ) (leave blank if none) <br /> 7. Is this to correct a violation? Yes ❑No ❑Don't know <br /> hk' 4,K 6 C/ 0I/ 6 Q ]Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/05) /� /'l�/ /! �f 4 I/! a V / 3 <br /> (Continue on Back) -♦ <br /> $/d06, 0 b <br />