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ZONING PERMIT APPLICATION www.countyofdane.conl SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME '�, <br /> j ' '"pis e' Zoning Status; CUP; <br /> OWNER ADDRESS (Number,S reet,C State,Zip) <br /> Li 3�^ L>i f iayx", Deed Restriction; CSM <br /> i Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> i d r. "' ,� �' b • /?9 f �� Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / / /1 �'` CONTRACTOR NAME <br /> ' f � X11 13X 14- s ite Plan including Iocatio / <br /> AGENT ADDRESS f_ ^ 4 Cup p TO`��,ppRES� _ /Ji' A of well/septic <br /> (City,State,Zip) (City,State,Zip) 4 A <br /> rgbetbacks C 0©kVA) <br /> �r <br /> PHONE �",,�,E� /�/ � PHONE i �`S Y6o5 pvt Site Plan approval from �,I <br /> D 7 69 J IC `r-' `�`�` 4.a9 )g 6 .06--9 r� dLy-applicable township. fr"/4- <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> , =mod Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: A / CURRENT ZONING: ACREAGE: .3 Elevation of property <br /> ❑ NUMBER /2//——D/3 C CO` —19 A r I �� 2, g frontage drawn to scale. <br /> :::: rr t /' SECTION:C O t-¢.- r ©/ 1h. , c T f-- / (state,county,) <br /> et'l <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary p- its <br /> „--- t (Public, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: r / <br /> �J X 2.1.1 /` Cd S ©a r`,r Zoning District "/2 X' <br /> . krhis project is . new buildi •.or structure. c b-e..6t %., <br /> Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. c' <br /> SANITARY SERVICE: PERMIT NUMBER: •'-PASRural,��A--d-dt ss r <br /> SEWER nsEPTIC � (ne 1e) lsting} <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not inc'I ' g basement) <br /> -'Wet Elo_odplain/`. <br /> AREA TO NEAREST SQUARE FOOT: C Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) /1-- 1 Erosion Control permit E', <br /> BASEMENT: 1ST FLOOR: J i <br /> /a 7 O + TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> 6 V filling/access) ,} <br /> 2ND FLOOR: 3RD FLOOR: / 0 r,� 0 <br /> lJ { Review Location Survey it <br /> cU -4. -4. -0- J 5 a and available options. ::04 <br /> tom Cy'"`"'"'( 1000 feet from a pond or lake? ❑Yes DiNo ❑Don't know <br /> et D-,..6,./ F :property? ❑Yes a No El Don't know <br /> r project and are they in agreement? ®Yes ❑No <br /> gos emar.j C, s property in the past 5 years? ❑Yes u No <br /> variance (petition/appeal# ) (leave blank if none) <br /> ❑Yes ©No ['Don't know <br /> ['Yes [2No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* --► <br />