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ZONING PERMIT APPLICATION ww .countyofdane.com SUPPLEMENT to Web-App# <br /> w <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> //19. >�t7ra • i� Zoning Status; CUP; <br /> OWNER ADDR SS (Number, ity,State,'Zip) ��' <br /> Q , � �-r- q Deed Restriction; CSM <br /> l& C 1 it 7r7/0QI' a I"") � ' I Variance(# ) <br /> HOME PHONE CELL E E d AILADDRESS <br /> (,o$3S$ -'-/(� )1 h1q, , 144,11(‘ Co V') Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE TINANdE`A ',,�/ CONTRACTOR NAME <br /> AGENT ADDRESS �1' L Z CONTRACT' ` LS Site Plan including location <br /> let c77-f T ' <br /> DkESS of well/septic <br /> (City,St te,Zip) (City,State,Zip) Setbacks <br /> (City, Via«, �� sus s r at r ye ,ups S3Sq o <br /> PHONE PHONE ❑Site Plan approval from <br /> 60f g5g-3-Mo4 I, 6( _ 3S --,2,gS0 applicable township. <br /> E-MAIL'D RE S E-MAIL ADDRESS <br /> (I,y1O , • tiv&!(,C pim AJ,I\- Floor plans to scale <br /> PROPERTY/LOCATION iNFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE' levation of property <br /> ❑PARCEL (N I I 3 &r_ qdo fz-' Q frontage drawn to scale. <br /> NUMBER (NT / J ��P I r� <br /> TOWNSHIP: SECTION: ,�/ <br /> �l Uv1 P‘reA4t, %a: '/a%a. I2 Driveway perm' <br /> (state,county,town <br /> ADDRESS: <br /> 41'0121 64[ Q q <br /> a I n pi c i i-1 - uJ1 - �3 S 1 Q Sanitary •- :• <br /> CSM: LO SUBDIVOION BLOCK/LOT (publi private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESC IPTION: _Ct�Q� oWtQ, W' � QttyCt fl(D'Inf-fOrdil1(.e0.1dFLi <br /> oningDistrict <br /> . <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 PEPTIC I3—AoIS- 009.1 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionControl permit <br /> 3 3 / 4, TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 00 filling/access) <br /> 2ND FLOOR � g���, 3RD FLOOR: M l <br /> t A ` I ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: o6(, --r)6 <br /> (Please round to nearest dollar) <br /> ♦ ♦ ♦ ♦ ♦ 0`0 v v and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes rallo (Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes alo EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? '®Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves ,alo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 1og I ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Yes QNo Don't know <br /> 7. Is this to correct a violation? Elves RINo <br /> 545-112(4/08) <br /> S APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br />