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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER AME • <br /> (�,1\3 S C-0 E L L- eg- Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) teed Restriction; CSM <br /> 101, L r•,)/Q,S\ n) cf'TO✓!v 14n3,J ,J5-- ,l'-7-11'77 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAI}} DDRESS <br /> .�3, L(SL, ' 33-( L�_,-- -JC J - /5 7 4 CJt-(�i40,1, Co-.- ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION land includes dimensions <br /> AGENT NAME CONTR'CTOR NAME �1 <br /> ( j C- (C / ._((1 (r S IDI Site Plan including location <br /> AGENT ADDRESS CONT. OR ADDRE S f well/septic <br /> (City,State,Zip) (City,S'te,Zip) L__I Se's acks <br /> It -7('I S-2,17 3-- <br /> PHONE PHONE ❑ • e Plan/clpp al from <br /> X04 4. 1299 _ Z'2 7 !..plipeible township. <br /> E-MAIL ADDRESS E-MAIL DDRESS <br /> r - tom, CMG $30(C aJ; cam h Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://ac:cessdane.co.dane.wi.usl) , Elevation of property <br /> PARENT PARCEL NUMBER: /, CURRE (�ZON G: ACREAGE: <br /> 0 PARCEL C∎ ��, M � `f ' MO ‘0 R 1-1— ,- i � frontage drawn to scale. ' <br /> TOWNSHIP: SECTIO :1 /� <br /> �Z Ll�r.)0 . 4: Sl-= '/4'/4:�J� V) ❑Driveway.p rmits <br /> ADDRESS: (state,,;-r;ounty,town) <br /> \t ..3 L.. LANC a K c.,30 - rt='cv, 't o t t-itp-) -"''- 5-3 S`�' 7 ❑Sanitary- ermits <br /> CSM: a •CD LOT SUBDN SION BLOCK/LOT (p"ublic, private) <br /> PROPOSED PR _PROJECT INFORMATION I STAFF REVIEW <br /> PROJECT DESCRIPTION: , ` r <br /> Z"( K .F n 1O L c o xr /j , �t toning District <br /> his project is a new building or structure. c�Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structur <br /> SANITARY SERVICE: PERMIT NUMBER: ' ❑ RuralAddress r <br /> EWERiEPTIC �� (newiexisting) <br /> HEIGHT IN FEET: i �NUMBER R OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ .2 <br /> t <br /> Shoreland (attachment) t <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ?Cpc ❑ ErosionControl permit ( <br /> l TOTAL SQUARE FOOTAGE: j (slopes, disturbance, i �I filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey , c <br /> ESTIMATED CONSTRUCTION COST: /L, �� 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? ie No ❑Don't know <br /> t <br /> 2. Is there a wetland or floodplain on or near the property? es ❑allo Won't know <br /> 3. Have you talked with the township about your project and are they in agreement? [✓]Pes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ENo <br /> 5. Is this project associated with a rezone/CUP/vari nce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) E Yes ENo DDon't know <br /> 7. Is this to correct a violation? ❑Yes []IVo <br /> . APPLICATION MUST BE SIGNED <br /> �� -► <br /> 545-112(4/08) <br /> r- � (Continue on Back) -► -► <br />