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$ <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-A pp# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 2 2 <br /> G S ,_,( (6CJ Zoning Status; CUP; <br /> WNER ADDRESS (Number,Street,City,State,Zip) f --� Deed Restriction; CSM <br /> V°2D( W � �� • �1 �3� 2_ Variance(# ) <br /> HOME PHONE / CELL PHONE I E-MAIL ADDRESS <br /> ( �3� �j) / b --2-2g-Z cr7S- tite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C-1--g7 Qii G J'Lbw (1)Ac Site Plan including location <br /> AGENT ADDRESS CONTRACT ADDRESS of well/septic <br /> (City,State,Zip) (City�State,Zip) Setbacks <br /> HONE PH\'ONE �P j ,Si an a proval from <br /> . A—xj U applicab wnship. <br /> E-MAILADDRESS E-MAILADDRESS <br /> C_Floo s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> 4 PARCEL rfJ Z S C LI rontage drawn to scale. <br /> NUMBER pie F- 133 - X300� � �F'� 1 1 -f <br /> TOWNSHIP: SECTI <br /> / `-f '/'/a: Drivew ermits 2LviMbl/)�75 a: S <br /> (state, unty,town) <br /> ADDRESS: _ <br /> S/. M S ; ° J Sanita ermits <br /> CSM: 5,�� LOT SUBDIVISION BLOCK/LOT (pU rlvate) <br /> rl <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION 'f4 s <br /> � <br /> � C G GE _A Zoning District 9 <br /> . p This project is a new building or structure. (123W1I3 C))■)b tx-. -0OCaG� Permitted Use`rl <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NU E51 Rural Address <br /> ❑SEWER SEPTIC (new Istin° <br /> HEIGHT IN FEET: NUMBER I S ORIES: (Not including basement) <br /> ❑ We E ood} lainf <br /> Shor attac ment <br /> AREA TO NEAREST SQUARE FOOT: ;i <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ' ;a: <br /> BASEMENT 1ST FLOOR: ❑ E.° 'i 5 trQl: rrYllf <br /> 1 �J j TOTAL SQUARE FOOTAGE: + (Slope • Stem) Circe, <br /> 7' fills ace s) <br /> 2ND FLOOR: 3RD FLOOR: -- I <br /> 13 Review =atfOri Survey <br /> ESTIMATED CONSTRUCTION COST • -.► $ � and a Jae optons - <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 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 jill 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 y No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />