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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> /'o/n/7 57u/2A Cv E - STE✓f .%i-'!Al S ❑Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM
<br /> 30 90 Cc4ME,LCE 1),(.._ ,44,4P15 c'Al w/ 537 i 9 Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> Sy 7.Z5-q, (4,S1 0 f t ;5 @ .,41›./. cc.,,` ❑Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> ...7-0.514 Ti5'S/,‘.17 v1,/ 4PPLc?a,i SiL-�., Com C ' "A 'Y ❑Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> Zyoc Ho&�y RD Z4o0 (pisLL/ ,4 ).
<br /> (City,State,Zip) (City,State,Zip) ❑Setbacks
<br /> 44.--EA/4 WI w/ Cl/95-( A/a-Am Hi w! fc/gs C,
<br /> PHONE PHONE ❑Site Plan approval from
<br /> 92c- 37S . ;v 9 o 9�c, . 759 , f , / applicable township.
<br /> E-MAILADDRESS E-MAIL ADDRESS
<br /> c 5AA' 0 a P 1rtals,`.-,...• ct'"••- cj+1fi(� 7(p/e-testi5':7". . Cep ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:
<br /> ❑NUMBER (al b g 0V. $(psb 9- l,,- �- (P-al frontage drawn to scale.
<br /> TOWNSHIP: SECTION:
<br /> 441P p L c'7v,✓ 1/4: ,/4,/4: ❑Driveway permits
<br /> ADDRESS: (state, county,town)
<br /> 3690/31c,v (..6AAme,tte D,-, ,M,ta:s.•--/, %Ai1 5-37,/9
<br /> ❑Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION: (- )NccW ill"iU- 5/0A) FA(-6 4CPc�tCCA4CJTs Fx,,p,i,,c
<br /> , c„6„4 ❑ Zoning District
<br /> ❑T is 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 /> FIEWER SEPTIC (new/existing)
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> ❑ Wetland/Floodplain/
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> Shoreland (attachment)
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> BASEMENT: 1ST FLOOR: ❑
<br /> ErosionControl permit
<br /> 4, TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance,
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> filling/access)
<br /> ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ -0. -.o. ♦ --► $ 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 ❑No Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? Des ENo [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 ❑No
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# (o(#3 ) (leave blank if none)
<br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No [Don't know
<br /> 7. Is this to correct a violation? ❑Yes ONo
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -i —►
<br /> 545-112(4/08) ( u ac ) ♦
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