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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 /> !b F1-v 112 + rYN AQ-t,A -roc TE Ef Z ing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> e- eed Restriction; CSM <br /> J9(Vo t),/RA �z ae mi C-,6 6e-1-Q61 lrJ► 5 2--) ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6°:7 64- 5z3 3 S. e Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION nt includes dimensions <br /> AGENT NAME CONTRACTOR NAME , <br /> SAM� mit to Plan including location <br /> AGENT ADDRESSHRIS MILLER CONST. LLC CONTRACTOR ADDRESS well/septic <br /> 3186 KINNEY RD. <br /> (City,State,Zip) COTTAGE GROVE, WI 5352-, (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE I I Sjte Plan approval from <br /> (,o3-2-O(o—I (°- Applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / <br /> (j.►r r s.cn'.(lor-c.+ns-'rvck1� ,,,t-CAti- , 11 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL �, frontage drawn t scale. <br /> NUMBER Olen( •-Ztn L— 1 �S 10 -- R IA I.�J I ► <br /> TOWNSHIP: SECTIONi iq vV ., I\j e <br /> Co-riaGe G 2rn/c 2 Co 1/a: •`3 '/%: ,-. ❑ Driveway per I s t <br /> ADDRESS: (state, county,town) 4 I/ \ <br /> 1 R. VC' v� . <br /> �1o,R fZ C.�sICA f�� G g�vE ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public;private) <br /> PROPOSED PROJECT INFORMATION /STAFF REVIEW <br /> PROJECT DESCRIPTION: nom, <br /> DerfAC-H3 CNA g-■ ( ? k la Zoning District <br /> . ,This project is a new building or structure. Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural As i ress <br /> SEWER SEPTIC <br /> (new/e isti <br /> HEIGHT IN FEET: NUMBER 6F STORIES: (Not including basement) <br /> J 1 Li Wetland/F dplain/ <br /> / Shor nd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) r' <br /> BASEMENT: 1ST FLOOR: ❑ ErosionCoRtfol permit <br /> `_-1 2 4, TOTAL SQUARE FOOTAGE: 4, (slopes.6isturbance, <br /> lD filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ,a <br /> r4 <br /> ❑ Review Location Surve* ■ <br /> ESTIMATED CONSTRUCTION COST: ♦ -p -p ♦ ♦ ♦ Q� --)C-( 6�� '�Q and available options. d <br /> (Please round to nearest dollar) �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? n Yes XiNo n Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'BYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes XNo <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? ❑Yes RNo <br /> 0 APPLICATION MUST BE SIGNED <br /> J� 4 (Continue on Back) -+ -i <br /> 545-112(4/08) <br />