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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE I <br /> .)Ksotn I�Y1t7 Ke(l I�tkL�.(Clz <br /> N Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM /0 n <br /> atp cn 3 tp ok Ile y Iz d Sim ky t o ru_W t 5 Seto ( ) <br /> y Variance # / '' <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (tai P,0 -*trio !t7/257(f 694 KS f-{tkl-1 l - 76 1Y1/1 I-CO'✓4 )j Site Plan drawn to scale I <br /> AGENT INFORMATION CONTRACTOR INFORMATION -nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> tkYzlal3oi r BL a-lio (ZS Site Plan including location <br /> AGENT ADDRESS CONTRACTOR DDRESS of well/septic <br /> *12.a-t,31P Do tie., o 5-0/5 1' <br /> (City,State,Zip) (City,State,Z' <br /> �y,/� �jry� ,'1 (� Setbacks <br /> ii W 1 5g 0I\PHONE V Site Plan approval from 4- <br /> PHONE <br /> tecxe, Loai <br /> 3111 pplicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> — Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: ��y �/CCURRENTTZONING: ACREAGE: Il Elevation of property <br /> ❑NUMBER O O"l ti—aqt— Y IN — i Q(.0 I <br /> 7 frontage drawn to scale. i <br /> TOWNSHIP. SECTION: <br /> 12)et5t01 '/4: %IA: KDriveway perm�it� / <br /> ADDRESS: (state,county,IOwr}►) l <br /> alolo 3 Itvwpy Uot tle y led Suvl P1rLt v--i e Wh S•3590 Sanitary.., its /� /i <br /> CSM. LOT SUBDIVISION BLOCK/LOT / V/ <br /> 'I t 1 y _ public pri .t- ` <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> tit tUYin ( 'SmMt1 'hovse b v-r-1 /4 Zoning District 14 '—/ <br /> This project is a new building or structure. <br /> in Permitted Use? X /vO p8 <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Ad• - <br /> EWER {EPTIC air IN FEET: I NUMBER OF STORIES: (Not including basement) <br /> 1 Wit lc, Wetland/Floodplain/ <br /> ) / <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachmen <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> XErosionControl permit <br /> aso + TOTAL SQUARE FOOTAGE: + (slopes,disturbance f� <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Review Location Survey, <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ n r, and available options. i zr- <br /> (Please round to nearest dollar) tJ D d, �(/ <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? ❑Yes No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ElYes ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Wes No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#1e) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ao ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ,®No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(8/09) <br /> (Continue on Back) - –I. -+ <br />