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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME , I <br /> CA- 1`M1 - 7. 1∎.(Z '—F=S VL I ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> Q-13 C1-100.0-) D L Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> • '3 S'-14 bt ' 1 ( 2—to 8 G ( M ' j -5 C SilwA- . , ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> (2,4.a"( CO E t -a .Q(ZEgrv` L - S i$/.rg ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDIIESS of well/septic <br /> 5 T l l V GitamAr 12.04.0 S((-1 A/.4- <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> AUpt)o.+ 43 -. 531(( Al A-4 t510.,) GJr S-37i( <br /> PHONE PHQNE ❑Site Plan approval from <br /> (o g-_444_Os's 4 ( O g--2-01-7S^t applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Iv t Ea r A' ti, Y-: c.o ..,q75.-Utit1 A7- 1) 'i ker. CU,rk ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdano.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CORD,TZ NING: ACREAGE: <br /> ❑rNNUMBER _Q so9-6 i24 -80�-0 H 3 ?- 3 is; 5 frontage drawn to scale. <br /> TOWNSHIP: SECTIION: <br /> 1-6C46 p'F nter4 r�/0 (o %.:S E %%: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 191 Zg • dN t/'1--1.. Y 0 -BPS-`e ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ( ' / (public,private) <br /> I l : g, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:� <br /> -.-A3 to6i■c)VX113 PMC)L. '2..b x 4 D = $ceo 4 ❑ Zoning District <br /> . <br /> 'gl, <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 WEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,---, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ?..LC) �`�` r�tZ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ SO Dry° <br /> f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 12Nlo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Jo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? tales DVo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? E]Yes alo <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 slo ['Don't know <br /> 7. Is this to correct a violation? ['Yes slo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -► <br /> 545-112(4/08) <br />