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ZONING PERMIT APPLICATION .countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER NAM <br /> /IC i !f ! ! gr„,t- e d II Zo •ng Status; CUP; <br /> OWNER ADDRESS (Number,Str tnCity, -te,Zip) D ed Restriction; CSM <br /> ( 6 g3 P,C Q/E/e V '9k) jf'! V L a nce(# ) <br /> HO PHONE CELL PHONE E 'IL•'DRESS /►_ <br /> 3 .67o A(.9 kik • 57/ 0 G al• • eaIn ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION nd . dudes dimensions <br /> AGENT NAME CONT-•CTOR NAME <br /> Si Plan including location <br /> AGENT ADDRESS ,�/� CONT-•CTORADDRESS well/septic <br /> , <br /> (City,State,Zip) ,V (City,Sta e,Zip) Setbacks <br /> PHONE PHONE ❑•ite Pla :pproval from <br /> appl; ..le township. <br /> E-MAIL ADDRESS E-MAIL•DDRESS <br /> IV Fl••r plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMB R: b e URRE T ING: ACREAGE: II levation of property <br /> ❑NUMBER I��72 " 02 7/C�-7' �r 3 I frontage drawn to e. <br /> TOWNSHIP SE TI: <br /> 's ry 1 '/a: .s %/a: to Li ❑Drive permits <br /> ADDRESS: e ^ e,county,tow. <br /> a t�k e U; e� ❑Sanita :-rmits <br /> CSM: LOT SUB IVI'I. BLOCK/LOT (p). . ,private) <br /> PROPOSED PROJECT INFORMATION " AFF REVIEW <br /> P 0 CT DE C IPTION: <br /> p q'-L ' J ` • Z•-ning District <br /> . ❑This project is a new building ot'`�tructure. <br /> IN ermitted Use? <br /> ❑This project is an addition/alteration to an existi • building or structure. <br /> SANITARY SERVICE: J PERMIT UM_FR - F-1 Rural <br /> W <br /> EER EPTIC (new/ xisting <br /> HEIGHT IN FEET: /01 ( NUMBE-OF STl/ORIES: (Not including basement) <br /> ❑ Wetland/F plain/ <br /> Shore d (attach ) <br /> AREA TO NEAREST SQU•RE FOOT: <br /> (Outside dimensions including unfinished area, attached g-rages and above grade decks or porches) <br /> ❑ ErosionCon permit <br /> BASEMENT 1ST FLOOR: //L/ 111) <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes, • urbane, <br /> filling/ cess) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 4/1(0.0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -•► ♦ ♦ ♦ ♦ and available options. �le <br /> (Please round to nearest dollar) ©/ <br /> 1. The property is within 300 feet of a stream or 10011 feet from a pond or lake? es o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es ❑Don't know <br /> 3. Have you talked with the township about your proj-ct and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this pr..erty in the past 5 years? Elves <br /> 5. Is this project associated with a rezone/CUP/varia ce(petition/appeal# ) (leave blank. none) <br /> 6. Is a location survey required? (see reverse) Oyes o ❑Don't know <br /> 7. Is this to correct a violation? Dyes EINo <br /> --I4 g..... --.■-- APPLICATION MUST BE SIGNED <br /> 545-112(ep) (Continue on Back) -► -+ -+ <br />