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ZONING PERMIT APPLICATION .countyofdane com50 SUPPLEMENT to Web-App# <br /> ,-14 4,,..... -, D ,A•to <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> '5l ekt 14A-cA/ t+ '(17 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 7 7S? ..S a S T c 4 C T- T-�,.r(r' tit1/JA(- j .✓ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS (��� <br /> [RSite Plan tl'rawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> --Z-/M Fr - IS(.4 is ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (C m A2 6(?/2--(6(7,C1 1".4.3e-y <br /> (City,State,Zip) (City,State,Zip) 41 Setbacks ���d L c S', <br /> '7`C tti„ cif "tic 61DL.,t ra—, <br /> PHONE PHONE ❑Site Pla ap r I from <br /> 2;7 Q 6'5 7 / applica <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 2e vne,c8(4,`d,cam,, e,4. ► ,,, ,Floor pla4 scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation f r ert <br /> PARENT PARCEL NUMBER: CURRENT NING: ACREAGE on p y <br /> ❑PARCEL frontage d n to scale. <br /> NUMBER c l?vb_ !cif- ,1-o I <br /> TOWNSHIP: SECTION: <br /> 0 F- tlet'80 LS re U IA: ' IA: ❑ Drive rmits <br /> ADDRESS: <br /> (statel ,town) <br /> y?3? S o�S�, ckl G T ❑S it per its <br /> CSM: LOT SUBDIVISION BLOCK/LOT ({ r "v A(�( <br /> SI4LKI<. F I (�V1�> <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTI`OO: <br /> ecl(1` .-.0,tc*I_ ❑ ZOAr trict <br /> . This project is a new building or structure. ❑ Per i ed Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> ANITARY SERVICE: PERMIT NUMBER: ❑ Rural ddress <br /> FIEWER IEPTIC (new/e ail•) <br /> HEIGHT IN FEET: A V Is- <br /> AREA 1 NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetl oodplain/ <br /> Shorrl ('attachment) <br /> TO NEAREST SQUARE FOOT: <br /> (Outside dimensions in ding unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: <br /> ❑ ErosionCQ of permit <br /> ,-- 10 4, TOTAL SQUARE FOOTAGE: (SIO rbance, <br /> filli /access) <br /> 2ND FLOOR: 3RD FLOOR: lo <br /> ❑ Re Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ©o coil and e O Ons. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes *II o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑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? ❑Yes ❑No <br /> Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> Is a location survey required? (see reverse) Ogfres ❑No ❑Don't know <br /> Is this to correct a violation? ❑Yes a o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0 -0 -0 <br /> taros) <br />