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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> 4 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ct1n es R 1 ► C._ Zoning Status; CUP; <br /> /OWNER ADDRESS (Number,Street,Ci ,State,Zip) /� Milli Dr Soo, t7J 4 Deed Restriction; CSM <br /> �i��s �rt/f M is £ 4 y Y Y' ' S a 7 0 � Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4.14 G y 92' ,2/0- J-81 7 2 , j 6L7i e Gi M7LCY n e4 ,Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTQR NAME <br /> Ic2 Z/NZQ 'I Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> W. 5-5-13 DI'iaY1000a r• <br /> (City,State,Zip) (City,State,Zip) / Setbacks <br /> PHONE P HONE e L /Z r ❑ Site approval from <br /> 60� - 0 G_17- 0 O 5-O op • ownship. <br /> E-MAILADDRESS E-MAIL ADDRESS ' <br /> *Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) g Elevation of property <br /> PARENT PARCEL NUMBER: CURREN-ZONING: ACREAGE: <br /> ❑ NUM ER OS o°I -a-) 1 -o G 7-1-/ R-3 . as j frontage drawn to scale. <br /> TOWNSHIP: SECTION h' ❑ Driv ay ermits <br /> -i S� p 0-7)-- -7 14: , `� 1�4 Y4: X/r.'"1.- (state unty,town) <br /> ADDRESS: v <br /> P)/S 3 1 s �- ,qL.� o�S'e '�-. - Y' ❑ San' :p •ermits <br /> CSM: LOT u dN[IStON BLOLOT <br /> c, r-xse,, 1_ o <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ` <br /> �-GS ✓\ �► 0-cc-IC- Zoning Districf r <br /> . ❑This project is a new building or structure. -APermltted Uses <br /> 6This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Ai,R,ral ,. .• a t tz <br /> EWER ❑SEPTIC 1 , ti " <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) 1 ' ' <br /> i 1 ' WetlandiFloodp sal r <br /> — Shoreland (a e <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches - <br /> BASEMENT: 1ST FLOOR: EI'OS10n0n�pc +e`7,,,i;:,::,+:6,,,' <br /> TOTAL SQUARE FOOTAGE: (slopes,disturb- e, <br /> S fil[In s/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> �-.-S 0 Revie OCation Surve r <br /> ESTIMATED CONSTRUCTION COST: and af?fe o ons , <br /> (Please round to nearest dollar) "� `� i t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? li 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? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes liKlo <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► —► <br /> 545-112(4/08) <br />