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ZONING PERMIT APPLICATI9N www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1 v t u t Bing Status;CUP; <br /> OWNER ADDRESS (Number,Street,city,State,Zip) Deed Restriction;CSM <br /> -.Y 7 Q I S l r(�Ids S *O U� �d r) LV j 5�37r?�f Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADD ESS <br /> [2LSite-Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> c✓'t la V{ S Ut e{ 5J-e ✓-e Sot( ( aySitalan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> z-70 ( S�-ro pr . Z -76I 9 -CoU $ Dr. <br /> (City,State,Zip) (City,State,Zip) 1 tbacks <br /> sI-00,1i Dr) 1-" I 53.519 .1-oU9ihOn wI S35 '9 <br /> PHONE PHONE ❑ Site P approval from <br /> 6 Qg — S Z$ — 3 S LJ ‘08 — 6 2'_ 3 5 Li a lica a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS o <br /> Su'[ t r t.-i/a /- ca <br /> 7 Gmo 1 , ,, iS(1f-e r t-va)l- w G-m7 o( ► corn F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL UMBER: C RRENTZONI, 'ACREAGE: ❑ Elev: ': of property <br /> ❑ NUMBER 01/67i) —1941-9374-5 p-v 0?9 To , 5 fro, .ge drawn to scale. <br /> TOWNSHIP: SECTION: Drive C(7f 9 & ro✓i I c1 4. t 1/4%: , permits <br /> ADDRESS: <br /> e, aunty,town) <br /> z96$-2(76 of Rd co air Grove /1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT El Sani rmltS <br /> lN\ , A • • c private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Oe c lc 1- ' x / 0 ing District <br /> ❑This project is a new building or structure. [ itted Use? <br /> 121his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT IyUM ❑ Rural Add - s <br /> SEWER SEPTIC 'hv/ /7 (ne * isttng) <br /> HEIGHT IN FEET NUMBER Orr1JSTIRIES: (Not including basement) <br /> ❑ We • .• •.•'plain/ <br /> Shor- : i (attachment) <br /> AREA TO NEAREST$QUARE FOOT <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 0 Eros!.• ontr■I permit <br /> ' 0 j TOTAL SQUARE FOOTAGE: ,`, (scopes , • ■rbance, <br /> 2ND FLOOR: 3RD FLOOR: fllling/-= es') <br /> 1'"p ❑ Review c- '.n Survey <br /> ESTIMATED CONSTRUCTION COST: and av- i9 : o tions. <br /> (Please round to nearest dollar) ♦ "'∎ -4. -+ -00 -II. $ 72_5„06 p <br /> f <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E No ❑Dt kr�or <br /> 2. Is there a wetland or floodplain on or near the property? DYes [ lo ❑Don't knob <br /> 3. Have you talked with the township about your project and are they in agreement? Dyes ❑NO <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes []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) Dyes [✓f No ❑Don't knob <br /> 7. Is this to correct a violation? es ['No <br /> APPLICATION MUST BE SIGNE <br /> 545-112(4108) <br /> (Continue on Back) ■ -0 — <br />