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ZONING PERMIT APPLICATION www.countyofdane.com F=3=1= <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER NAME <br /> •••-f r Afer/1 JJ o..cs Zoning Status; CUP; <br /> OWNER ADDRESS (Numbe,Street,City,State,Zip) <br /> 9�t�6 "7,re.rc•� Deed Restriction; CSM <br /> °'`� ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 66gsr7 4;"(fy°2- Gat*-2/5-63 2 56 Mc- f rc,fa2 Ca1 , .cri.., dS' Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION a d includes dimensions <br /> AGENT NAME CONTRALTO NAME <br /> corn ,...\c.:1 c„,r it Plan including location <br /> AGENT ADDRESS ONTRACTOR ADDRESS P of ell/septic <br /> (City.State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE ❑ ite Plan ap val from <br /> ( .-.11S-910t.) (n042-X0-SIA pplica ownship. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> A ■cl. Iry \•COQ F oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn levation of property <br /> PARENT PAV,EL NUMBER C RREENTrZONING: ACREAGE. P p y <br /> ❑NUMBER o�°2'a)t". . uo-� p_�� 11.�,� frontage drawn to scale. <br /> TOWNSHIP; p/i�O SE=� J� /d E ❑Driveway Its <br /> VV� 1�4.� lC� ��4��4. /" 4-� <br /> ADDRESS: (state, unty,t n) <br /> 66 Q,\,ers�ae. (13 <br /> ❑Sanitary rmits <br /> CSM: 6-1 LOT / SUBDIVISION BLOCK/LOT <br /> r 5 � j'► (p.blic, rivate) <br /> PROPOSED PROJECT INFORMATION •TAFF REVIEW <br /> PROJECT DESCRIPTION <br /> Of>"\- � �D C, St_— • •ning District <br /> . lgjThis project is a new building or structure. <br /> 'ermitted Use? <br /> This project is an addition/ Iteration to an existing building or tr c re. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural A res <br /> EWER EPTIC (new/e fisting <br /> HEIGHT IN FEET: I u NUMBEf3OF STOR ES: ( including basement) <br /> I ❑ Wetland/F odplain/ <br /> Shorel d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionCont permit <br /> ��i ) j TOTAL SQUARE FOOTAGE: + (slopes. turbance.. <br /> 2ND FLOOR: 3RD FLOOR: �`+ fillln CCeSS) <br /> ICOO ❑ Review Location Survey ftiTh <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ $ ©QO and available options. <br /> (Please round to nearest dollar) D(p, <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? fYes No ❑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# ) (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? Oyes [X]No <br /> � <br /> _ APPLICATION MUST BE SIGNED <br /> 545-112(aloe) ( l7 <br /> /�y (Continue on Back) --■ <br />