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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> ' PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW RNA1 P l\ r'1 So <br /> S e Zoning Status; CUP; <br /> OW ER ADDRESS (Number,Street,City,Step,Zip) <br /> 39 1 �tr r� '/ Deed Restriction; CSM <br /> T Vero eNQ 1 wr 35 3 Variance(# ) <br /> \AOME PHONE CELL PHONE E-MAIL ADDRESS <br /> GOFC 5" Z5— 99 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG iri,E D CONT CTOR NAME <br /> KP: keS J op r f i RM�S ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 11715— elegy, 41) ic^736 1 l ,) <br /> (City,State,Zip) (City,Stat iip) etbacks <br /> V PHONE PHONE Site Plan approval from <br /> VI s 2J ^5.3'=3 applicable township. ) <br /> E-MAILADDRESS // E-MAILADDRES <br /> 74' , e,,, f{vr0tsi '' loo, cvt0.-1 , , 71i ieo 4 4rv.tor..„...., Floor plans to scale 0" <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) c4\U <br /> PARENT PARCEL NUMBER: CURREN/IZONI G: ACREAGE: Elevation of property cJ <br /> D PARCEL NUMBER 0 JT(S"detS_950 o /'�—l-e X t� frontage drawn to scale. <br /> - TOWNSHIP: SECTION:: < ■ . ,• - <br /> 9 ,..4-1'p s-e l� 1%: S w IA IA:iu Z= -.►� <br /> ADDRESS: /,'"? (state : nty,town) <br /> • 1� 1 fn k-- ,e), 0055 Au.:(,S , CJ'Z 53593 San •ermits <br /> CSM: LOT SUBDIVISIO BL K/LOT <br /> I I `) q °� °�/ (public, <br /> PROPOSED PROJECT INFORMATION /� ST FF REVIEW <br /> PROJECT DESCRIPTION 1 1 <br /> l( io v (Gzt-rat 19 S'Atildoet Zoning District <br /> f . <br /> . ❑This project is a new building or structure. ; .Permitted Use?' <br /> )4This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Adss dre ; <br /> ❑SEWER SEPTIC (n., (Oft f„,:. , . ' <br /> HEIGHT IN FEET I NUMBER OF STORIES: (Not including basement) <br /> 0 � f etland/Flood) I, 7 <br /> AREA TO NEAREST SQUARE FOOT: ho eland (att'hmen �� I <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> Eroslbraill rai rfi® <br /> BASEMENT: 1ST FLOOR: <br /> f 4, TOTAL SQUARE FOOTAGE: ,` (sloPes,idisturb t e, <br /> °?�� fillingfaccess) <br /> 2ND FLOOR: 3RD FLOOR: OZ L\ ©0 <br /> L® ion Srirvey„ <br /> ESTIMATED CONSTRUCTION COST and a options „ <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ -* $ '\--).1 000 ,, .., - <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ONo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EiNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes EiNo <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 lallo ❑Don't know <br /> 7. Is this to correct a violation? DYes allo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* —► —► <br /> 545-112(4/08) <br />