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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CU:TOMER TO PROVIDE <br /> OWNER NAME _ <br /> MI ChAd and Kcrhe If en%eYSO1l [ oning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) teed Restriction; CSM <br /> Z�O b Camfy eol 3, V Yohq, WI 53593 ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> roog• 5%(o ' i Iberfs0nKatl.6 e h(a•COM S' a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d i cludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> MI k ACitri0 P Sit Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS O ell/septic <br /> 2-7-0 CON POI gol I <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> / I/4 53513 I PHONE PHONE le Plan approval from <br /> (Mg' If 6/(0-1(42- plicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http Jlaccessdane.co.dane.wi.us/) Elevation of pro <br /> PARENT PARCEL UMBER: CURREN ZONI G: ACREAGE: P p y <br /> ❑PARCEL d —i14' />to-o <br /> NUMBER 6 I frontage dra to scale. <br /> TO HIP: SECTION: <br /> �rv)gala te It 1/4.� E 1/41/4:-S C ❑ Drive y permits <br /> ADDRESS: (st ,county own) <br /> 2 -12o Co4nly rd r VeYvh / 53593 <br /> , fl .anita .ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 1 (pub' , private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> f hkASe Midi-Nil -- 'i Zoning District <br /> . <br /> This project is a new buildi g or structure. r Permitted Use? <br /> ,his project is an addition/ Iteration to an existing building or structur <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ' :fore.s it .FIEWER EPTIC (new existin. <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not inc ding asement) <br /> /q 1 <br /> ❑ Wetlan✓r loodplain/ <br /> Shor: and (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area ttihe rages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ Erosion ntrol permit <br /> l ' IF TOTAL SQUARE FOOTAGE: 4, (slop ,disturbance, <br /> 2ND FLOOR: 3RD OOR: fillln /access) <br /> FL <br /> L <br /> I / x <br /> f l ❑ Review ovation Survey <br /> ESTIMATED <br /> nearest CONSTRUCTION COST: and a ailable options. <br /> (Please round o llar) —► -► ♦ —0. —0. —11. $ <br /> 1 <br /> i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes .No fDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes o ['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 ❑ <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank f none) <br /> 6. Is a location survey required? (see reverse) Dies o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> (2)/0 <br /> 545-112(4/08) APPLICATION MUST BE SIGNED <br /> (Continue on Back) —0 —► —► <br />