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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NNE <br /> /" C- / • /9�2� Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3C/9 /1/4L7-1//4 -' 1 (O774y ! 'i254 G(// - 5-..?, 7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADpRESS (�, <br /> 669- 23 -BSS/ &;-vZ3 -• i% riChct_rd. •Q.r- ec/. • - -(x mite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 0 Site Pl.y- ding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS S ,- I/septic <br /> (City,State,Zi p) (City,State,Zip) Setbacks C / J` <br /> / <br /> PHONE PHONE Site Plan approve fr� r <br /> applicable township. �� <br /> E-MAILADDRESS E-MAIL ADpRESS <br /> La-floor plans to scale ( <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.ca.dane.wi.us/) r�1 7 2 I <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: LI-El,evation of property <br /> �j �� 7 frontage drawn to scale. i <br /> NUMBER 0/?/01// -3345/ /C_ / / ' I <br /> TOWNSHIP: SECTION: <br /> 07 07?. '/4: /1/w %I%: dii p Driveway permi <br /> ADDRESS: <br /> (state,county, ow'') <br /> Cs�J /1/4-7--v7 ,e2> co' 7-729( 64v6, UI / s--35—z/-7- g Sanitary e :.. <br /> LOT `� SUBDIVISION // BLOCK/LOT <br /> � (public, gate <br /> -.) /eca,A;' GL'ffC S <br /> PROPOSED PROJECT INFORMATION STAFF REV( W <br /> PROJECT DESCRIPTION: �� <br /> v. . T' // )4 Zoning District #?/ <br /> U This project i a new building or structure. Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. �G�s�a� <br /> SANITARY SERVICE: PERMIT NIJMBER: Ai <br /> Rural s 57-4-1/ <br /> ❑SEWER U'S`EPTIC (new/ (sting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> //..--r / / Wetland/Floodplain/ <br /> Shoreland (attachment' <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached aaraces and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ErosionConI(OI permit <br /> 4--i< /c X16 /2-2. ;)F,— 1 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 1 �/,/��2 <br /> j9Z <br /> ' T a Review Location Survey 4� <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ UCH �� and available options. .� <br /> (Please round to nearest dollar) <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 LaffC ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0"Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes allo <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 11K0,,__,// ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IdNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —+ —► -0. <br /> 545-112(4/08) <br />