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I 7(967 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> ` <br /> tar * is c i s i e'11Z h 14..L. <br /> OWNER ADDRESS (Number,Street,City,State,Zi ) ❑Zoning Status; CUP; <br /> 3S/°) a ID i ,-kd Deed Restriction; CSM <br /> HOME PHONE �� Variance(# ) <br /> CELL PHONE E-MAIL A DRESS <br /> boat rn 3/4 1183 tole% - bso 3 FADb lr ...A-O• as • ire } <br /> AGENT INFORMATION CONTRACTOR INFORMATION ❑Site Plan drawn o <br /> AGENT NAME and includes dimensions <br /> CONTRACTOR NAME <br /> AGENT Ve c4V6'41 AC L 1. c. El Site Plan including location <br /> CONTRACTOR ADDRESS J^ of well/septic <br /> (City,State,Zip) 3o�t, � �+�/ Wr. <br /> (city,State,Zi ) a 0 Setbacks <br /> PHONE %� W I J 1 <br /> PHONE ❑Site Plan approval from <br /> b loci — b s'O 3 applicable township. <br /> E-MAIL ADDRESS RESS <br /> E-MAILA D <br /> M tbi�to fa TbS . fief Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> 0 PARENT PARC NUMBER: CURRENT ZONING: ACREAGE: ['Elevation of property <br /> PARCEL <br /> NUMBER 01-2 /V Z os -2 ts-93$"`b 4,x a R .1-1 frontage drawn to scale. <br /> TOWNNSHIP\ SECTION: J <br /> �1■�\XA," Z ? 1/4; w 1/4.1/4. S W ❑Driveway permits <br /> ADDRESS (state,county,town) <br /> 3 gqa •)4 41-,. . <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> VI. 5 I c a. (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: `` STAFF`REVIEW <br /> ��''� Mme' t 0 COI' u-i ') S.f4 ❑ Zoning District <br /> • ❑This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. ❑ Permitted Use? <br /> SANITARY SERVICE: PERMIT NUMBER ❑ Rural Address <br /> EWER RTEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> I c 1 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑EroslonCon%rol permit <br /> 1 STY0 i SO V j TOTAL SQUARE FOOTAGE: j (Slopes,disturbance, <br /> 2ND FLOOR. 3RD FLOOR: filling/access) <br /> — <br /> 30 X0.0 <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location Survey <br /> (Please round to nearest dollar) —0. . —0. -0. -0. -0. $ q 0 O • oit7 and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes ENo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? NlYes ['No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? &fres ['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) ['Yes No ['Don't know <br /> 7. Is this to correct a violation? ['Yes tiklo <br /> Z . <br /> Z Q 0-K) APPLICATION MUST BE SIGNED <br /> 545-112(8/09) (Continue on Back) —o. —► <br /> 27 <br />