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Imo, �6t6. <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Ij rY\ 1—LT1r so''') ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> rnn / Deed Restriction; CSM <br /> cq /'r CO <br /> \ s4' 4- • I r l 4 t'` "b' i 535'7 2 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 3'7 5- z1-4 3 3 539 / Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME 1 CONTRACTOR NAME <br /> —1(31-"‘ H*Y1.I p rScon ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/se. ' '` <br /> 4( "7 PcD Ee.- } S-1 <br /> (City,State,Zip) II (City,State,Zip) 0-Setbacks V <br /> rY\ - 14c.(-k_h ( k)) 53S-7 2 <br /> PHONE PHONE 1 .1 Site Plan approval from , r <br /> 9 3 '7 5 Q i q applicable township. /V <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> � <br /> 1L Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> ❑ <br /> NUMBER ER �(0 A - 5 d frontage drawn to scale. <br /> TOWNSHIP: SECTION: 1/4 1414: fit] Driveway permits p <br /> r �.,1� : (state,county,t �V&' <br /> ADDRESS: <br /> a I- ® Sanitary permits <br /> CSM: �� LOT SUBDIVISION BLOCK/LOT (public, private)br6 T <br /> PROPOSED PROJECT INFORMATION STAF RE ..#1 f�, <br /> PROJECT DE RI LION: <br /> � a� c <br /> ���1 � �Yl ` v' 'Q/�(S h t1 �� ❑ Zoning District <br /> . This project is a new building or structure. �+ <br /> ❑-Permitted Uses <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1M Rural Addr <br /> ❑SEWER ill SEPTIC I (ne exi n+ Vail <br /> y <br /> HEIGHT IN FEET: l + (! NUMBER OF STORIES: (No including basement) 8'. <br /> t `�/) elated/Floc In/ <br /> Shoreland (attttac me g; <br /> A TO NEAREST SQUARE FOOT: 3 <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) . <br /> COSIO [l.9.-! E:[mtt <br /> BASEMENT: iSTFLOOR: , ■ <br /> w Woo, 621' Ij TOTAL SQUARE FOOTAGE: (� lopes,disturb a OGaD_ <br /> 2ND FLOOR: 3RD FLOOR: �� <br /> ._ view Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> —► —► —► —► _•.. �� ' 0�� andavallab' . ap#ions,: <br /> (Please round to neares dollar) <br /> .he property is within 300 feet of a stream or 1000 feet from a and or lake? .. ❑Y Don't,p 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? 13 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? CI Yes 6I'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) El Yes ca No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► —► —► <br />