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.. ti( " b 0 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ret.n le 4 cl ,,/kii ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Num Street city/state,Zia)1/ / '/ C- Deed Restriction; CSM <br /> 771 !/ G #/` LfK / zdl .5- 33"---- <br /> Variance(# ) <br /> HOME PHONE C HONE ,/ E-Mfj/ADDRESS <br /> a 73V A- 7 T ' ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG/b NA E C CTOR NAME <br /> r"' a/7e 1 4z, 1 e jefi ,8h/ii 5 7.../. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /fl 2 .v Ja%d& / 1) as A) mv,lec �' <br /> (City,State,Zip) (City,State,Zip) y • Setbacks <br /> L4/lt-U 244' W/ �C1.A.)rut/4u_ <br /> PHONE PHO r II Site Plan approval from <br /> 6'f PM 77' . ' g fvy �7/D J applicable township. <br /> E-MAIL ADDRESS E- IL ADDRESS // <br /> >rj _/e •a t!sF6r. - S. ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (hitp://accessdane.co.dane.wi.usi) El Elevation of property <br /> PARENT PARCEL NUMBE : CURRENT ZONING: ACREAGE: <br /> ❑ <br /> PARCEL voi -164/-A,f g <br /> frontage drawn to scale. <br /> ` <br /> TOWN SEC!TOP l / V� 1/a: $1 5-,E //a: 5( J <br /> ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑Sanitary permits <br /> CSM:0/ 9�a LOT / SUBDIVISION 4 SUBDIVISION (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> ['This project is a new building or structure. ❑ Permitted Use? <br /> rtject is an addition/alteration to an existing building or structure. <br /> 1 <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ RuralAddress <br /> )EWER PitE155C -7 0 '7 7 (new/existing) <br /> HEIGHT IN F3 T / 1 Q` NUMBER OF S-ZSS: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> EA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions incl • unfinished area,attached gar d above grade decks or porches) <br /> BASEMENT: / (. 1STQOR: ❑ ErosionControl permit <br /> ``// t`�/ I� X/ / n� TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> l ` �/ filling/access) <br /> 2ND FLOOR t� L 3RD FLOOR: , ,(A/ <br /> '� (�O `� o'o `�'4�`]��1.�)( ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ and available options. <br /> (Please round to nearest dollar) ♦ ♦ -.► $32r O/�� <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes EINO ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes L ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes [. 46 <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) DYes QNo QDon't know <br /> 7. Is this to correct a violation? ['Yes ['No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -. <br /> 545-112(8/09) <br />