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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 /> 51'`awv` M • S r" +t-t ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> G 9 a b M o L.‘ L.. h r C&I . Si C'' -e (,.J i S 3 C9 v Variance(# ) <br /> HOME PHONE CELL F5HONE E-MAIL ADDRESS <br /> Gods -.113.-c.4a3 VvNA-te 103-c I eopekCFer , 0.I- ❑Site Plan drawn toscale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Sew M, S vv ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Sue( Pc... t Wz S3S9v <br /> PHONE PHONE ❑Site Plan approval from <br /> Got - av a - Ga.- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> \r.o.v I t h V.S'1 e L\.wc 4e , v\c+- ❑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 S19 frontage drawn to scale. <br /> NUMBER CYa/OCM -as.).-0as3-a p,--N • <br /> TOWNSHIP: SECTION: <br /> '-owe- o(- Cis 's• °1 TO° tJ 'Z11C a4 1/4: N c" WA: N441 ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> t• 5 it Mecr 1-;.5%.4 Cc. S„r Pc.:.c %,.,s S35-5v <br /> CSM: LOT SUBDMSION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> L&r '71. S.,t-se f R:4 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> \8' ' Zo' SkQ■...�e SV.ei.k • .. 4-\ud-A,"-) Ccorsc IC,kt- Slgg ❑ Zoning District <br /> . ®This project is a new building or structure. ❑ 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 including basement) <br /> 11 r 1 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ ErosionControl permit <br /> 34,o j TOTAL SQUARE FOOTAGE: ,' (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 34 O ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -I. -4. -40 ♦ Sid O c u and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes giNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes slo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EgYee ow <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes KiNo <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) es ENo ['Don't know <br /> 7. Is this to correct a violation? es klo <br /> t APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -+ <br /> 545-112(4108) <br />