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10'4 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME en i <br /> r I +o`e s r' ck A aSZoning Status; CUP; <br /> OWNER ADDRESS (Number, eet,City,Slate,Zip) � <br /> ..7 57 f CO(l. C4 i :,1i;r s-+ k):7- 53C 52- Deed Restriction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS , VarlanCe(# ) <br /> 19b4 7U , -IJS-CD°/ $ Y,acl0ke-c x.(46(,' I�&' s.zc:.�� <br /> RI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NA E CONTRACTOR NAME <br /> J ! bits`1 1 tt4/'I 1c ( >. L 4-4- 4 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRES of well/septic <br /> (City,State.Zip) (City,State,Zip) jaNSetbacks <br /> PHONE PHONE ❑ Site pproval from <br /> ap ' a e township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CUR p7ON7G: ACREAGE: p p y <br /> ❑ PARCEL 1 0 0 ') - a A r 0 -Z rontage drawn to scale. <br /> NUMBER � <br /> TOWNSHIP: 1 SEC ION:�y I <br /> Luc/\�So r '7 1/a: NW(A)w WA:51 ,,4J ❑ Drivew permits <br /> ADDRESS: (sta ,co nty,town) <br /> n`O <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sani .! .ermits <br /> I t s pi -- (pub•-, •rivate) <br /> PROPOSED PROJECT INFORMATION at, ''.,,STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> i4.)ck. 9-oracle- c) p-ccA '"" Zoning,District � <br /> . Ai6his project is a new building or structure. Permltted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural ` o° Sy°= <br /> ❑SEWER ❑SEPTIC (new/ xiSttng 3 11 a <br /> R <br /> HEIGHT IN FEET: I NUMBER OF STORIES: (Not including basement) <br /> 1 a J5 Q wetia / adpraln! <br /> Sh d (attachment <br /> AREA TO NEAREST SQUARE FOOT:; <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Ervslo,C= trc permit <br /> BASEMENT: / 1ST FLOOR: _ <br /> I/I 4, TOTAL SQUARE FOOTAGE: 4, ,,(slope +lstu1r® Oe, <br /> 2ND FLOOR: 3RD FLOOR: ftl)t acs ss)t s ' <br /> ReVie dart Surv'e <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ ♦ y� an Val [?fe(pttE,,nS <br /> (Please round to nearest dollar) lam✓ ' „ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? CI Yes tNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes gNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 0 N <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? SiKes ❑No <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 grNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aioa) (Continue on Back) —► —► —► <br />