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ZONING PERMIT APPLICATION wwrw.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> DQ' YY h'r` [ Loning Status;CUP; <br /> OWNER ADDRESS (Number;Sireet,City'State,Zip) ' , Deed Restriction;CSM <br /> <c)"J.f ' ,\ C ;, j« '( ;� 7. - •t , " ( : _ Variance(# ) <br /> HOME PHONE 1 CELL PHONE E-MAIL ADDRESSS <br /> 453% -$y73 160{- ljy- ' LJoc, 4►''_. ;New 6 ;. '-,;. , ,►\ Site Plan drawn to scale <br /> AGENT INFORMATION ;CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME COOTRACTOR NAME ,. <br /> MI a,'a. PI\ (\''✓L: ,,i,1.__(. C)( Ci t r I 'e f '' r\ [t ite Plan including location <br /> AGENT ADDRESS , p CONTRACTOR ADDRESS �-�/of well/septic <br /> ` 0 M C CO vv l'1 F f 1 / et __. _.__A Lrl <br /> (City.Sate,Zip) (City,State.z,p) Setbacks <br /> PHONE PHONE , Site Plan approval from <br /> '("' C 3? - Z 7'' v y applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:;laccessdane.co.dane.wi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> Li NUMBER Cell dill so `f 1 A I•C7C 0.(0 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Plea 5-a .+ 1'r t 0 S '/: 1/41/4: (state,a <br /> r o n) <br /> ADDRESS: <br /> 3I MCCO4tKC!!ROI <br /> CSM: LOT SUBDIVISION BLOCK/LOT L2 nitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DE IPTION: ,auk <br /> A el d , l 0 IA -L. c"‘I..1 ? R' `T h ( (' ( Zoning District <br /> DThis project is a new building or structure. (ZDerrrlitted Use? <br /> [ this project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural <br /> EWER ryiEPTIC ( xiSti <br /> HEIGHT IN 4 NUMBER OF STORIES: (Not induding basement) <br /> 1 ei Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: 64 s. permit <br /> 3 . 2c, j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> Sling/access) <br /> 2ND FLOOR: 3RD FLOOR: 3 <br /> - p Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -I. -�► t.{Q loo and available options. <br /> (Please round to nearest dollar) i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes [ Vo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes o DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes [lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies 3' to <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) Gres C o ODon't know <br /> 7. Is this to correct a violation? Dyes J34o <br /> APPLICATION MUST BE SIGNED <br /> 545-112('106) <br /> (Continue on Back) -r -► -t. <br />