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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ,✓lCE L No,E "c. P/C lTi�/ ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City, te,Zip) <br /> 3757- ,Bnool�Ly"/ b'z- 1lok reAt I, ?, 5 6,1 <br /> Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 69-5-313Z2- ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> p74• , il✓& M4e)ges/es/74 LW 772 Cl i&A( ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ..K. 23y Po/30>e 23171 <br /> (City,State,Zip) (City.State,Zip) ❑Setbacks <br /> c'c0,e, r� l', 5.s'S ' 0777-46a 1:i0wti't /-GI/ ,53527' <br /> PHONE PHONE ❑Site Plan approval from <br /> 6 -. -.71d_.5- _..5-7-3'- 6+4/0 5- applicable township. <br /> E-MAIL ADDRESS . E-MAIL ADDRESS <br /> W/ g 44 I GD' - G al/0 46 f Go,-— ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ®PARCEL ala_zsy_ 92954 /243 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 2eNN 25 '/a: SA" '/a'/.: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> SZ S Z &lot:.a[y,✓ lam- 3bvl6t1 fan! <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: `" <br /> /G e/Go'li✓/Z,..../. ' "3v"/r'>s/"" f //Zx/3^b"4vVA,6, ❑ Zoning District <br /> . ❑This project is a new building or structure. C°/- rX/6' '��QD�O�"j <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> Z-6-- p�� / ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,---. ErosionControl permit <br /> BASEMENT: Ace,/ypt-1ST FLOOR: /245# C (Il' 4 TOTAL SQUARE FOOTAGE: j (Slopes,disturbance, <br /> //121 2sa U✓, //12 *//Z : /Zy0 l filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 3SZ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available options. <br /> (Please round to nearest dollar) '♦ ♦ ♦ ♦ ♦ ♦ $ 2 . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? !Wes ❑No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? filYes alo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? likes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑1'es ISNo <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 EIVo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —I. <br />