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A <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> itY1,C)G211/44, 17-147-1--e k EUXE ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ' r s '6°2447• fl O edict..,e /ylJ!!- , im , C,c:14 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .QL. . M 4Lcc., pAemiat.,5 LL,C ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> T Brix 41,%01 p <br /> (City,State,Zip) (City,State Zip) El Setbacks <br /> HA ` , l 5314/9 <br /> PHONE PHONE El Site Plan approval from <br /> X)8 , +a3 —6l 2s applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> M aid,'• a,rti-,crs .r.,671, ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: _ CURREN ZONING: ACREAGE: p Elevation of property <br /> ❑PARCEL 1 44 � t �,1 I.�. frontage drawn to scale. <br /> TOWNSHIP: 0102 1 `"1 (015N S A-A .��c _a F <br /> k /�h` � SECTION: <br /> �!/e ' ,/a: ,/,/a: ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> CSM: LOT SUBDIVISiOQL--", BLOCK/LOT ❑Sanitary permits <br /> ittLt iN`• (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: `` _ <br /> SAN" AJ�'W C )/,� A t----- ❑ Zoning District <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 EPTIC (new/existing) <br /> 9 Fakir HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> "2. 5- ` It 7- LI Wetland/Floodplain/ <br /> i�v�i' AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> lJ (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: J 1ST FLOOR: ❑ ErosionControl pen-nit <br /> /t ', 30/C) 1 t 0 ,` TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> 2ND FLOOR:_ 3RD FLOOR: ` ;5� ���S filling/access) <br /> l/' y _°� <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ 3-7D� �U 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 go ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LIves o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes jalo <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 !j, o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ■ o <br /> i 6),Ul2b APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> �� (Continue on Back) -4. -4. -► <br />