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ZONING PERMIT APPLICATION www.countyotdane.com 11-111:i 4 ,'I 4:1i 'LM" "A <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> A .J 4 0L�H r t ❑Zoning Status; CUP; <br /> WNERADDRESS (Number,Street,City, ate,Zip)� Deed Restriction;CSM <br /> 30 3 1 v wit>, 17 c/ 1�1 /�C ry fe / �i 3.�S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 2 . 0' 0 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> `4M 6 s FYI tiev4i ei 6A441 Ai,i W4,ss. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /2 Oct 6---nfeeper•se "b/- ,5) (, `Iiiheoft. ' - <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> lie PHONE , / 0/ E3S`>, PHONE Pe /pt. �� 5 3S'T ❑Site Plan approval from <br /> I applicable township. �XA- <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale tc^ <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> ❑ <br /> PARENT PARCEL NUMBER: CURRENT ZONING: REAGE: <br /> PARCEL <br /> NUMBER c 2(r✓/1'CGI-I f 30.0 R N • ( $ a frontage drawn to scale. <br /> TOWNSHIP: ` SECTION: <br /> f�er� S�vt f 5 Sri '/4: '/a'/a. ❑Driveway permits <br /> ADDRESS: V S ,f / 1 (state,county,town) <br /> 303 G4/ . AA1/Vt 4/(j r/gkir 63 ❑Sanitary permits <br /> CSM: • LOT I SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> D-c achei 4/44 r z7)` .3 ❑ Zoning District <br /> . Y1This 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 /> DENVER 163TIC (new/existing) <br /> HEIGHT IN FEET: /�i NUMBER OF STORIES: (Not including basement) <br /> /J ❑ 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) <br /> Li ro <br /> BASEMENT: 1ST FLOOR: sionControlI <br /> OO <br /> 4 TOTAL SQUARE FOOTAGE: j, (slope 15LIIr tce-�Z <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access)pe pe <br /> a,4 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �1 is -.2.:1.."- and available options. <br /> (Please round to nearest dollar) --10 ♦ --► --► -P. ♦ $ � go°. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es io on't know <br /> 2. Is there a wetland or floodplain on or near the property? L ❑es EN0 ont 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 ❑Vo <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) Des No ❑Don't know <br /> 7. Is this to correct a violation? :Yes _No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ —► <br />