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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION Cu:TOMER TO PROVIDE <br /> OW KR NAME <br /> �C 6 <br /> fr A\CLi -I2 5 E Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> '2_ 7 6, 5 -Q»c v, (\ w ` ed Restriction; CSM <br /> r� ( J ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (o()b y Z3°►-3690 a e�,, ee c\,,-cA. C'' r,„,hao , (..oen Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ( ik1 J p f CV f\ C(i-v) on la_wA ,65S CC, ❑ e Plan ' luding location <br /> AGENT ADD ESS CONTRACTOR ADDRESS f we eptic <br /> (City,State,Zip) (City]�State,Zip) Setbacks <br /> 1 I G�� ,s t� W �� /e <br /> PHONE PHONE ❑ t: Plan royal from <br /> 00E- j112 -2)01 ,aplica etownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> K-1(0-t,A c-I ^n 2l.e ,,,•.o.A. c c Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER R TZONING: ACREAGE: t v Elevation of property <br /> ❑ PARCEL C)(0/10.- C W.0/' 7. CR , 1 ? frontage drawn to scale. <br /> NUMBER �O `, l <br /> TOWNSHIP: SECTI <br /> !PUN N 1/a. ,S 1/41h: ❑ Driveway mits <br /> ADDRESS: � (state, Unty, own) <br /> 12-- ) (e) U -1 v v■i•-e"ir l ❑ Sanitary •-rmits <br /> CSM: LOT UBDIVISION > publi •rivate) <br /> - wt.O oSe Pail BLOCK/LOT <br /> PROPOSED PROJEC INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ' I <br /> 0 r(\t _ ) ` t A-1 017\ L...1-) oning District <br /> . ❑This project is a new building or structure. Permitted- ? <br /> Ft-61s project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVIC • PERMIT NUMBER: ❑ Rural A reSS ' <br /> SEWER nSEPTIC , ``. (new/exi <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not inclu ng basement) <br /> 2:n ❑ Wetland/FI dplain/ <br /> Shore! d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ ErosionContro ermit <br /> BASEMENT: 1ST FLOOR: <br /> Z X19 1 TOTAL SQUARE FOOTAGE: 1 (slopes,dis rbance, <br /> 2ND FLO1 R:1-. � 3RD FLOOR: filling/ac ss) <br /> "' j G--/ ❑ Review Location Survey 1\ <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ d available options. <br /> (Please round to nearest dollar) Ya� CO C)0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes Rlo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o .Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? .... ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes n No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank,none) <br /> 6. Is a location survey required? (see reverse) ['Yes 01\210 n Don't know <br /> 7. Is this to correct a violation? ❑Yes allo <br /> 545-112(4/08) APPLICATION MUST BE SIGNED <br /> �� (Continue on Back) <br />