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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> OY2 Pc N ° SA-M Rv -S sELL. ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> IQto�Z TAktZTAN - ►- • Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60S.Glq 5tolob WS.$34.Z9loci bb= ' vss-etJ r tom' 'I- ®Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> P7en ��neu,� Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A RESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> cT 1e i viN 1 W, - 6,AZ <br /> PHONE PHONE <br /> El Plan approval from <br /> c i 9, c, -I N , 330 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> cv tfle,Wc krt C,+favi , , mai j.ern❑Floor plans to scale <br /> PROPERTYILOCATION INFORMATION (http:Ilaccessdane.co.dane.wi.usl) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: frontage drawn to scale. <br /> ❑PARCEL 3•3/249 } <br /> NUMBER CJtZ�ogtt-3o3-b3Lb-0 �- t S <br /> TOWNSHIP: SECTION: <br /> 0 . 0 1/4. 5W %1A, ❑Driveway permits <br /> �r� C ` (state,county,town) <br /> ADDRESS: telQ 2 1N Ilit_ . J1)N 2Nr\9-\`L, W‘ 5359 O <br /> , i ❑Sanitary permits <br /> CSM: LOT SUBDIVISION( Q.DE� BLOCK/LOT (public,private) <br /> I , I3V-ISTIDL. Ito <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> A-C>oi N G p-cY- ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER aEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ' ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 25 00 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 5® 0'0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 30070 UO 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 ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 'lo ['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? S,Yes D"lo <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 al <br /> Q�� APPLICATION MUST BE SIGNED <br /> ' �� (Continue on Back) —► ♦ —► <br /> 545-112(8/09) .7 <br /> ' 7 710 <br /> Il l <br />