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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU' O ER TO PROVIDE <br /> OWNER NAME <br /> B: I I w` d- ,Ec_rry J. © u rkpa s WA Z ing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Sl 5+ Z Ga u T /-} �t D ed Restriction; CSM <br /> Y �9hw,. ( ) <br /> HOME PHONE CELL PHONE Y E-MAIL ADDRESS rlanCe # <br /> 6os7 335-5657 boo• Thhouse e Gku rTe/' , n'tt S e P an drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd i eludes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> Sit Plan including location <br /> AGENT ADDRESS CONTRADTOR ADDRESS of ell/septic <br /> (City,State,Zip). (City,State,Zip) etbacks <br /> PHONE PHONE ❑Site Pla pprov rom <br /> ap I le to ship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ loor p ns to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.eiane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ONINGj ACREAGE: Elevation of grope <br /> ❑NUMBER O5o9—Z3/— 9z2a—q / �� i• p frontage drawn scale. <br /> TOWNSHIP: SECTION: <br /> 0 ('e S o h 22 '/a: Id r---- �y4y,;S UJ ❑ Driveway rmits. <br /> ADDRESS: (state ounty, •Wn) <br /> 5/`! 2 Co L.cpi T7 /-f:yh w ur ❑Sanitary .ermits <br /> CSM: LOT I SUBDIVISION BLOCK/LOT <br /> oo60 q `,ubli ,private) <br /> PROPOSED PROJECT INFORMATION `STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S.`ki 9 he- Ga ,r •a r-+x y e Zoning District ,' <br /> ❑This project is a new building or structure. permitted <br /> ®This project is an additio alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMITNIfMBER: ❑'Rural A S , <br /> ETEWER EPTIC (new/ex ting <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> p n e- CI Wetland/F odplain/ <br /> AREA TO NEAREST SQUARE FOOT:AREA d (attar ent) . <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ EfOSI0nC0 OI permit <br /> 4, TOTAL SQUARE FOOTAGE: , (Slopes ISturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/ cress) <br /> , " C' CI Review Location Surve <br /> ESTIMATED CONSTRUCTION COST: , and available options.. <br /> (Please round to nearest dollar) $ / 00 <br /> 1. The property is within 300 feet of a stream or 1000 fleet from a pond or lake? [Yes ®No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Olo ®Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? res ❑No . <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes No <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) [Yes No ❑Don't know <br /> 7. Is this to correct a violation? [Yes QNo <br /> APPLICATION MUST BE SIGNED---'a 545-112(8/09) ? (Continue on Back) --► <br />