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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW R NAME �}�, ,�/J a/ f <br /> ee,_)(n (3' s. r�/' l/ T f?c.. ,//'e01 y- i4 eie/i ❑Zoning Status;CUP; <br /> O NER ADDRESS (Number,Street,City,State/Zip) // Deed Restriction;CSM <br /> 512.z Ph ea-W/24 L rcinc-i Rd. WQ(J/ta cG 4IZ 535f�' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> C - '/8 `. - /06 • i 4 6 I` i r i()1 , C ou El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT <br /> T N ME CONTRACTOR NAME <br /> AGEN'(7'fl s V '„S�/1 BR i Gk,-. tRos - ,�i L 0 Site Plan including location <br /> CONTRACTOR ADDRESS of well/septic <br /> 5 a a-S4/11- t)laacI Ro( `/oo (3R IaKL Rd, <br /> (City,State,Zip) (City,State,Zip) �( )) ❑Setbacks <br /> f.)avhaktc Ai; 535g7 1JE3T sit k M1 ''"/ 54CG 9 Site Plan royal from <br /> PHONE PHONE approval <br /> ( sig. 52c -000 C (>Og._-�ff(o - 0 B 90 applicable township. <br /> E-MAIL ADDRESS �/ E-MAIL ADDRESS <br /> P/R0 Q► M 0, 7 i dQ . com s t 'G0 Ks , AP' _1 11 .i • ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: n EJ Elevation of property <br /> El PARCEL NUMBER <br /> �(SC7 4�5�' 910 R- (rx) 3e, ��X frontage drawn to scale. <br /> TOWNSHIP: n SECTION: CCC��� <br /> —' cJ' r i r► -T i c id '/a: '/a'/a: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 5----4-'7'Z Phea.scn7 13lt I RC/ Gtct.vna C'e WI 53599 El Sanitary permits <br /> csM s--\1\D LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION,: <br /> / t JAI k a,ro Li Zoning District <br /> -4 This project is a new building or structure. Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: �, PERMIT NUMBER: L7 Rural Address <br /> EWER I SEPTIC (new/existing) <br /> HEIGHT IN FEET: ) ��"�� NUMBER OF STORIES: (Not including basement) <br /> oZ G ( ❑ 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 FL OR: r---, ErosionControl permit <br /> 3 I TOTAL SQUARE FOOTAGE: I (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: �� O p (� <br /> / / ) ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q J ' and available options. <br /> (Please round to nearest dollar) $ ", '7" 1 r 1`0? <br /> 5sOi con <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es 040 Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Res Q <br /> es �Vo QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Wes QNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes QNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan I none) <br /> 6. Is a location survey required? (see reverse) [Yes Ef, o ['Don't know <br /> 7. Is this to correct a violation? QYes PLINo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) = = <br />