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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> /t ‘ PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE /4-/ <br /> 153 OWNER NAME �* <br /> /41 6- 1-- ►li c f lijitf,,k,t11,) Zoning Status; CUP; /v /7 Z <br /> OWNER ADDR S ( umber J ru S/� �eet,City..State,Zip) <br /> N <br /> g l " Cr pt� Deed Restriction; CSM <br /> c Variance(# ) <br /> 'M PHONE CELL PHONE E-MA ADDRESS / / 0 <br /> 6'8r2' -Co�� ��✓�-� (T�'�'�til• d i- Site Plan drawn t�arale�7� <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions ) <br /> AGENT NAME CONTRACTOR NAME f <br /> PIS sep.ti�uding locati <br /> 3 f AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> 1 tp <br /> (City,State,Zip) (City,State,Zip) :A Setbacks <br /> LJL <br /> PHONE PHONE ❑Site Plan approval from <br /> 'A4` <br /> applicable township. r/L i( <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 2A Flo. - <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT P RCELNUMB tR': CURRE TZONI G: ACREAGE: <br /> ❑NUMBER <br /> PARCEL <br /> S1L 'i q"f ogn-e A dC /5 � frontage drawn to scale. <br /> TOWNSHIP: SECT N C <br /> Alb 1 0 h �9 '/4: S G '/4'/4: S�� Driveway permit <br /> ADDRESS: /��/ O 4 �(r I_/ �, f fir i / (state,coun , own) <br /> 7 / O� Sanitary p • s <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public„an <br /> „..----, t"-------' <br /> PROPOSED PROJECT INFORMATION STAFF REVI <br /> PR T D CRIPTIO / / t jE r- <br /> i„ vy /i / ►k- 4- S 4 ►r►�t,l4 /4 �( r 7-d te✓'('C ( piZoning District ( IA /c <br /> ❑This project isane ing or structure. 1^0( f,0 /iV r r/ Z <br /> Permitted Use? OC r P <br /> This project is a additi /alteration to an existing building or structure. t <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> Rura -. / L/^ <br /> EWER ,EPTIC (n- 'exist) • 'Z Z T / <br /> HEIGHT IN FEET: //////������'''"' NUMBER OF STORIES: (Not including basement) / <br /> - gtland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Abp-.rosionContro{permit t <br /> BASEMENT 1ST FLOOR: j�.� p / <br /> 3 ,, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: q^G ,('U� 3RD FLOOR: <br /> ❑ Review Locati urvey <br /> ESTIMATED CONSTRUCTION COST: ♦ D0• MIN 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? ❑Yes lo. ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Y No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es ❑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) Eves ..Elao ❑Don't know <br /> 7. Is this to correct a violation? °.. ❑Yes ,❑No <br /> '1\\ • "{ APPLICATION MUST BE SIGNED <br /> 11 (Continue on Back) -► ♦ -► <br /> 545-112(4/08) , V <br />