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,'. <br /> to <br /> I <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> fOn�� �A h41lrG• ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,C ,State,Zip) Deed Restriction;CSM <br /> 47a y kop f , (/1/4 w.t,ak1t + W/ 535-17 variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> oY tYI.3)1'7 •8 a0'.ccS'1 61 A BS 13 6-71)5.4 ET ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> G leo rit RH,/dm, 40 r ❑Site Plan including location <br /> AGENT ADDRESS CONTRADTOR ADDRESS , of well/septic <br /> Po box 930)0o <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> Vtro„4 wt 5'3c4 3 -d»o <br /> PHONE PHONE ❑Site Plan approval from <br /> 4 or 7yc I7w applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS L I <br /> ero,i�i c./ hH++lM, ,G�►A� ❑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 pp QQ frontage drawn to scale. <br /> NUMBER boo _�s}I -8-loo _O SECTION: / �,�� <br /> TOWNSHIP: Driveway permits <br /> 5,r,,, /e/ w %: NE /•/•: "`"'"'CCC(state,county,town) <br /> ADDRESS: <br /> CIF 7'1 kV, Rl In/aw rakte, WI 533-47 <br /> \q Sanitary permits <br /> CSM: o53 6 8 (LOT SUBDMSION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 30 901 ?o 1C bestr. )tic k arioning District <br /> . la 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 A•:. :: <br /> EWER (ODD-FIG (new/ xisting <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> I S, / +t I ❑ VNeUend/Fk>odplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) i--% ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> I a,o() c.1.1�1 + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ).CO 4 a ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ p c� and available options. <br /> (Please round to nearest dollar) y 1a1 plc, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Ekes Ilo Ion't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes plo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes 1,No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Ekes Ilo <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) Ekes to �on't know <br /> 7. Is this to correct a violation? es o <br /> t'AD AP PLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -+ <br /> 545-112(aoe) <br />