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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> k� r ( D Zoning Status;CUP: <br /> OWNER ADDRESS (Number. .reef City.Sate,Zip) Deed Restriction; CSM�j� ,1 l CCLim. 14-3 <br /> 1`�-�--- !!S __ �t/CX�1 r � 1)7S ���_ Variance(# ) <br /> {H,JN E PHONE C� CELL PHONE 1E-MAIL ADDRESS /`•1 0 7 , "CO-b 1 %ST r(('t- Cs. -01c1 - cox^ 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG <br /> et) <br /> 'T NAME ICON ,ACTOR NAME <br /> teA(,U i Site Plan including location <br /> AGENT ADDRESS i CONTRACTOR ADDRESS of well/septic <br /> i <br /> icy-Sate._ !(City.Sate z pi Setbacks <br /> PHONE PHONE --- ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS tE-P,tA.ILADDRESc <br /> ElFloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (fittp://accessdane.co.dane.wi.us0 Elevation of property <br /> "RE?-iT PARCEL NUMBER :CURRENT 7ONfh^ ACREAGE <br /> P.a cEl frontage drawn to scale. <br /> ❑PiU.'.BER � 0 q La�VOlig Y- - tt' j t <br /> TO TSHIP ;SE Ti f,a <br /> (.1 1 terc o ,/d: '/4'/4: ❑Driveway permits <br /> �� TRESS (state,county.town) <br /> S fr,;(,;1 0 Sanitary permits <br /> OSM- !LOT cI• D!VISIOtd BLOCK OT <br /> 5 (/ t �c - J (public,private) <br /> PROPOSED PROJECT INFORMATION S• STAFF REVIEW <br /> PROJECT DESCRJPT!ON. 1 <br /> l / / 2[ 5Ii'e ❑ Zoning District <br /> . This project is a new building or structure. D Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> A — — -- - --- <br /> SANITARY SERVICE j;PERMIT NUMBER ❑ Rural Address <br /> DEWER E ;:C (new/existing) <br /> HEIGHT EET.' --- ._...-- ------ _L�—!`0.,'.%R OF RTES (Not.^�ud!^g basement) -- <br /> ❑ WetiandlF{oodplainl <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT I 1ST FLOOR.: - 1---, ErosionControl permit <br /> jj TOTAL SQUARE FOOTAGE: . (slopes,disturbance, <br /> ------.----__------: filling/access) <br /> 2ND FLOOR 1 3RD FLOOR i �.J!l/�� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST 4 and available options. <br /> (Please round to nearest dollar) -to. -low -I. -0. --► $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['(es 0 0 don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres a o DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? aes II o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes Dia <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) Ekes 'lo DDon't know <br /> 7. Is this to correct a violation? Ekes jao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -i -► <br />