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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 'WNEr,`NAA,,E <br /> �`-r;(''` Stn,til ❑ Zoning Status, CUP:. <br /> OWNER ADDRESS dumber.Street CEt.State 1, i <br /> r Deed Restriction, CSM <br /> _g_31_/_ !'��l /rOge- Ver191N- - •--&� Lj . _ Variance # ) <br /> HOME r H.C..NE 'ELL PHONE It-MAIL A.;DRESS <br /> 608.-1 , 6-�O ; 6. r,4litheo 0 4AeilF(-om ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ,CONT'ACTOR NAM <br /> 1 trikel • IY1/71) ❑ Site Plan including location <br /> AGENT ADDRESS f CONTRA:TOR AL `^ESS of well/septic frvi <br /> m see z,�, I �,cy.s-,t_ ❑ Setbacks <br /> ■i <br /> p,.c-NE 1 PHONE ❑ Site Plan approval from <br /> applicable township. <br /> EvALADDRESS F-MA LADDRESS -- <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.wi.usl) <br /> PARENT t PARCEL NUMBER I EURRE ZONING ACREAGE ❑ Elevation of property <br /> PARCEL �6�/ 1 y/������ /_/ 777 frontage drawn to scale. <br /> NU,:IBER oC . L- <br /> �St" h y- `!\ <br /> '� / �, /�/p %: /Y /� 1/41A: ,+J(/ Iri Driveway permits <br /> ADO E �C�!(� �J��Cj I /� — — (state, county.town) <br /> .3 -� fi " / O C g� " �r0� IJ Sanitary permits <br /> s-i I L 1 SUBD V:SiON !BLOCK/LOT <br /> f <br /> i i (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> / 't t f'C� IV ✓l e iv Ga k re�� ❑ Zoning District <br /> . I This project is a new building or structure. ❑ Permitted Use? <br /> Vi\This project is an addition/alteration to an existing building or structure <br /> SANITARY SERVECE I PERM,T NUMBER ❑ Rural Address <br /> J SE`JVF_R SI,SEPTiC i (new/existing) <br /> HE T iN FEET - 1 Nu ms.ER oi=STORIES ;N ■r,t;.udma basemen - <br /> ❑ Wetland/Floodpiain/ <br /> \ Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT <br /> ;Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT +_` �-DQ I,ST=L-,,,R -- l FAQ ❑ ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> fillip /access) <br /> R I 3RD r-LO .R filling <br /> /access) <br /> "° —__—i Z ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► $ j ^\ �L O �y y� and available options. <br /> ;Please round to nearest dollar; $ / l/ 1 Jam ( <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? .... ...... U Yes Ea No ❑Don't know <br /> 2 Is there a wetland or floodplain on or near the property? .0 Yes NNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? .... LI Yes ❑No <br /> 4 Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 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? J Yes ❑No <br /> -{ APPLICATION MUST BE SIGNED <br /> 54:7-111 4 <br /> L l,_L - . I (Continue on Back) -♦ -1 -i <br /> 0 <br /> Li V. :.i �c <br /> Li l <br /> e•) 0 f -. J <br />