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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OW NAME <br /> �2 , e.-c O..1Ve' `mss L Zo ng Status; CUP; <br /> OWNER ADDRES5 (Number,Street,City,State,,zip <br /> sityl i<4.lese.y Cf, sg ZZ. �c� r■4 kee 1A)Z- 53 S'9 D ed Restriction; CSM <br /> V riance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> d°2' 3.5Y-34205- i€stAker 4An 1YAIVe l 1 <br /> 3 S4 La,Conti it Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION an in udes dimensions <br /> AGE T AME/ / CONTRACTOR NAME <br /> fre, x Se/Au� DS ❑ to Ian including location <br /> AGF�,N?ADDRESS �� CONTRACTOR ADDRESS of W II/septic <br /> (City, ate,Zi`) r ' (City,State,Zip) 111 Setbacks <br /> Ott'(,50Itdr I (-e Gv S <br /> PHONE PHONE n Si Plan royal from <br /> 8y, -?�Y Z a plic a township. <br /> E-MAIL ADDRESS rr E-MAIL ADDRESS <br /> WO'G+�.,t� @ 4 ho, Cc. loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of prop <br /> PARENT PARCEL UMBER: CUR EN ZONING j ACREAGE p p <br /> ❑PARCEL �5'‘ U00842t(81i 0—3 D •l/ , 51 frontage dra o scale. <br /> NUMBER O �` (( f� <br /> TOWNSHIP: SEC . , (�-� , , w t Drive y permi <br /> 5P�►ny rc.�Q / J v�l /</.: rv�r (state,coup ,town) <br /> ADDRESS: a� <br /> S4'Cf( A est y 61 1 '014�" Q P 1i Z 5-35/ 7 <br /> ❑Sanit permits <br /> CSM: LOT �.c' ii BDIVISION BLOCK/LOT <br /> (p c,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / P <br /> Pvc:.s be-ck. K.() )(.(? • .ning District <br /> . �fhis project is a new building or structure. <br /> Li ermitted e? <br /> ❑This project is an addition/alteration to an existing building or struct e. <br /> SANITARY SERVIC . PERMIT NUMBER: Ij ❑ Rural dre <br /> EWER EPTIC (new/e Istln <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not indud g basement)(:)? ❑ Wetland/F odplain/ <br /> Shorela (attach nt) <br /> AREA TO NEAREST SQUARE FOOT: t <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionContr permit <br /> r^� j TOTAL SQUARE FOOTAGE: 4, (slopes,di urbance, <br /> tl� filling/ac ess) \ <br /> 2ND FLOOR: 3RD FLOOR: a <br /> 0 ❑ Review l ocation Survey 7U <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ S <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [ )o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes F/,"o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Lives JNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Lives ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank' none) <br /> 6. Is a location survey required? (see reverse) Lives No Don't know <br /> 7. Is this to correct a violation? Oyes ONO <br /> Gc AP PLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -* -+ <br /> 545-112 . <br />