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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA II __II I <br /> I'c I�It.S 0 I c�IA 5c ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street, <br /> F City,State,Zi ) c Deed Restriction; CSM <br /> HOME PHONE L' [, <br /> CELL PHONE E-MAIL nE-MAILADDRE S L� Variance(# ) <br /> 60g AA, -a.E' fZ fro-15, / IIP i, , Cowl ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> AI,'c k &045de, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ,'q-/ �wy N/ <br /> (City,State,Zip) (City,Staff Zip) ❑ Setbacks <br /> fol�.474n t 3355 <br /> PHONE PHON ❑ Site Plan approval from <br /> od f -?o ._o‘81` applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> CI <br /> Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ NUMBER 051/-3102--662/-0 A-02 /6_ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 3(0 1/4: /V E 141/a: /1/ / ❑ Driveway permits <br /> �U n k%r k (state,county,town) <br /> ADDRESS: <br /> I t? ii - N Ej , WE 535 3 9 CI Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIE1 ' <br /> PROJECT DESCRIPTION: 1` i <br /> Jk(j FrOni Porch 6iddi4i Yo ,aCl3)is fl ❑ Zoning Distract „,k.„,..,,,,, ,.....,./„,... . <br /> . This project is a new building or structure. ❑ Permitted Used°K:.. - <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Ad <br /> ❑ dress uN <br /> ❑SEWER ❑SEPTIC (new/existing)' P` A: , <br /> ems <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetiand/Flvodplaln/r ; <br /> Shorefancf (attachme, <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) l M <br /> EiaslonGQntrW perm' fit ` <br /> BASEMENT: 1ST FLOOR: <br /> 1 TOTAL SQUARE FOOTAGE: j (slopes,dISturb,0nce, 7 <br /> 2ND FLOOR: 3RD FLOOR: fll0-sy ±i <br /> yIng- ❑ Review Locatio *urve <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ ♦ and ayaflable opttvns <br /> (Please round to nearest dollar) 31� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 21-No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑Don't know <br /> 3. Have you talked with the township about your project an agreement? .- ❑Yes 21 No <br /> 4. Has there been a zoning permit issued for this iliac ast 5 years? ❑Yes 0 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) su... .\....2..0Q`) ❑Yes . No ❑Don't know <br /> 7. Is this to correct a violation? *Fes ❑No <br /> p1;@t�ptipttr�l�t;�C�`E.LOPt��Nt <br /> DANE APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ —s <br /> 545-112(4/08) <br />