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ZONING PERMIT APPLICATION www.count Y ofdane.com1 1'S <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> FA t— 1 N E`t <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Zr ( SILs( L 1 h.. .. JAR ST��i-F`fi�Ni V∎11 S Deed Restriction; CSM <br /> , , <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 2 8O —/ &-7• ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> • lS•ME PSC_,==*-r7TzAc_-t-rpe_ c.o.:p/TP.L_ wit vN ?.S iNc` ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 44c -Ic LT Piz) _ste,ios <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> M06.4D.1Sd», V4.1 53713 <br /> PHONE PHONE El Site Plan approval from <br /> 6,C�E-' --Z Z.Z.— S-4-. )CD applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> c.cppi-t-cm!bvi (r.Qers _.-I-JOs-net Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usI) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL �C.c.(1—Z92.-4305- R-1 Dolma z- frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> FLF4SAJ•ST 5 P-11JG S Z. '/4: -1/4'/4: ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> Z. ->--t I s K-(c_r s■I IG ( U <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: � Q 1Z-14,1 t_f/US.- /'■,-'b <br /> REPLN•� D�� �e.G� '1---A.,lS ❑ Zoning District <br /> . ['This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> %,,4.EWER rEPTIC (new/existing) <br /> HEIGHT IN F ET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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: 1ST FLOOR: r—, <br /> ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ --► ♦ — <br /> and available options. . <br /> (Please round to nearest dollar) /d,Dd <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 0 es ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres ENO <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres ENO <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) Efres ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />