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.- ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU ` OMER TO PROVIDE <br /> OWNER NAME‘ \F E`Q•,tt4 ,� �10v 4-\\).)c 4° p <br /> °z, . li Zo ing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D ed Restriction; CSM <br /> "tom�V► `�c1 e��a��, .� A \L) 53%13 V riance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADRESS <br /> clts2A''7>Z'Z 1 S' Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CCONTRA:TO NAME <br /> SUS \ Q l->p-Y) \ , •s�n�. Li Sit Plan including location <br /> AGENT ADDRESS+ CONTRACTOR ADD SS of ell/septic <br /> �I,. -.�,co ; Air 91 a <br /> (City,State,Zip) City,State ip) ❑Setbacks <br /> PHONE PHONE , 1 ❑Site Plan proval from <br /> .%'- Z•3--Z,1 applic le towns ' . <br /> E-MAIL ADDRESS E-MAIL ADbRESS <br /> A C.' oc'rtsk,-YnS� ,, cow, ❑ Fl or ans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) levation of property <br /> PARENT PARCEL NUMBER: [] CURREN r ONI G:� ACREAGE: P P y <br /> ❑NUMBER DUD ,©1 / `'1 l00Co 4 L ) ►'�)C frontage drawn to scale. <br /> TOWNSHIP: SECTION: h1I <br /> -C c7 1-1 1 1/4:- 1 vF 1/41/4: 5E, ❑ Driveway mits <br /> ADDRESS)`S' �1 VM��� ' (stat ounty,tow ) <br /> I.\ \`-'■ r , `A\0 VA ' <br /> CSM: LOT SUBDIVISION BLOCK/LOT El Sanita ermits <br /> (pu c,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO T D SCRIPTION: <br /> A0. i 0 --2.:,,tv‘o GL-e. : oning District <br /> . <br /> This project is a new building or structure. Permitted Use?: <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ' -. <br /> {)EWER / t EPTIC 1 (new/-xistin• <br /> _ <br /> HEIGHT IN FEET: ( NUMBER bF S�ORIES: (Not including basement) <br /> (c)... ❑ Wetland/F plain/ <br /> Shore d (attachment) <br /> AREA TO NEAREST SQUAEFE FOOT: <br /> (Outside dimensions including unfinished area attached garIges and above grade decks or porches) ❑ Erosion ntrol permit <br /> BASEMENT: 1ST FLOOR: i / y <br /> 4 TOTAL SQUARE FOOTAGE: ,+, ( op ,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: f II /access) <br /> 0' Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ,♦ ♦ ♦ + ♦ and available options. <br /> (Please round to nearest dollar) 2>© •ape <br /> i <br /> 1. The property is within 300 feet of a stream or 1000feet from a pond or lake? Dies ZNo ❑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? Dies No <br /> 4. Has there been a zoning permit issued for this pro{ erty in the past 5 years? w11Yes ;it <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blanone) <br /> 6. Is a location survey required? (see reverse) Ekes ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED 4 <br /> (I ________ <br /> (Continue on Back) <br /> 545-112(8/091 <br />