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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# , <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 0 <br /> /V1 I cH,f4- --L- C L=- k ut r T ( ►:4 Zoning Status;CUP; Q� <br /> OWNER ADDRESS (Number.Street,City.State.Zip) •eed Restriction;CSM <br /> 15 3✓ 1 i lit Q.vr S D rt t� Variance(# /) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 00 <br /> ,� -4�. - C _� - v • 'c. p . t: 'u • in Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATIONI and includes dimensions 4 Agc <br /> AGENT NAME CONTRACTOR NAME <br /> A <br /> rX-Site Plan including location /Q-P • <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks 60$ 14 <br /> PHONE PHONE Site Plan approval from <br /> applicable township. / ' <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpi/accessdane.co.dane.wi.us/) <br /> PARENT NUMBER eS RCEL/N MBE`i; , l�R'RENTZOIj►1{JG: ACREAGE: y �► levation drawn 0 PARCEL -0,c2-0 / (Jn K-2- 3 frontage drawn to scale. <br /> TOWNSHIP: c SECTI N: /Y J NE <br /> Li <br /> k ,,� � f r K � 1/4: ,/4,/4: Driveway permits <br /> ADDRESS: <br /> (state,county o n <br /> c' permits <br /> CSM. r 3 4/ LOT SUBDIVISION BLOCK/LOT AlSanitary <br /> 1// �■ �■ (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PR7TS IPTI <br /> /� x I ( v - ' d e C CQt Zoning District ip_ 2_ • <br /> . OThis project is a new building or structure. l--Si-C-j S 1-0 S r� XPermitt Use? /30 ► <br /> This project i n addition/alters Io an existing building or structure. CZ 0\/ D C-C t <br /> i <br /> SANITARY SERVICE: I PERMIT NUMBER: Rural Addr- 4- ti <br /> EWER /,�,.EPTIC ' (new/a •l� / <br /> HEIGHT IN FEET p I NUMBER OF STORIE (Not including basement) <br /> G./[ I AWetland/Floodplain/ <br /> Shoreland (attachment) / J� <br /> AREA TO NEAREST SQUARE FOOT: /� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: g Erosion Control permit <br /> l j TOTAL SQUARE FOOTAGE: 4 slopes,disturbance, <br /> filling/access) A `N <br /> 2ND FLOOR: 3RD FLOOR: <br /> /` Review Location Survey A <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ �/D© ®� 1 and available options. <br /> Please round to nearest dollar) V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes . !- o Don't knc- <br /> 2. Is there a wetland or floodplain on or near the property? [Yes :' o Don't knc:. <br /> 3. Have you talked with the township about your project and are they in agreement? Wes /No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes .111No <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) OYes No ❑Don't know. <br /> 7. Is this to correct a violation? Oyes 1No <br /> r� APPLICATION MUST BE SIGNE,-4(Continue on Back) — c <br /> ► •- <br /> 595-112(4/081 f <br />