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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE,4 NAME <br /> 610042__ '- &-719-71.---= —/V "- � E� Zoning Status; CUP; C - <br /> OWNER ADDRESS iNumber,Street,City,State,Zi Deed Restriction; CSM ) ?Yea : <br /> ea 3V W 14\14S«,..r4n) ..504 /44-01So 5 1j i . 370 3 Variance(# <br /> .PHONE CELL PHONE E-MAIL AD�RESS <br /> yam.• Zo0-- 'o7 r..cFvq,E <br /> x a RE. c.4. .•-, <br /> gre Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions �/ /) <br /> AGENT NAME CONTRACTOR NAME ! /6 <br /> LCM 3 A ,T4 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of V1ILIr <br /> 54,8S- AI 1 ze "4 Sr <br /> (City,State,Zip) (City,State,Zip) AA-"(5435 Setbacks c/...c l <br /> PHONE ) PHONE Mite Plan approval from <br /> Z.ZZ- 78 j--/5 vo applicable township. , /A_ <br /> E-MAIL ADDRESS E-MAIL ADDRESS 7y�I FIOOr plans to scale <br /> r,w►are✓1Q/a-�.' I ems► her- el eatr��c:. 4,•y .�� p i/ <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.usn <br /> PARENT PARCEL NUMBER: CURRENT ZO G: ACREAGE: I Elevation of property <br /> Q <br /> ❑PARCEL rontage drawn to scale. <br /> NUMBER a 3 Z7 7.2 y-3C f-7o01-0 - 1 Z` 3 A <br /> TOWNSHIP: SEC N:r\/ r <br /> ,/ 1/4: s 5 1/41/4: G Driveway permits <br /> /t/4-D'So.4 (state,county <br /> ADDRESS: '/� \ f <br /> 27 /�[o r'�n4+„� �,¢/c4.>a.� M 15 r, �I ( S 37/3 i� S. permits <br /> CSM: LOT / SUBDIVISION BLOCK/LOT <br /> /3 No+[�-r7v.z a-tocis sub'•, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: i / / <br /> D 01--F4c.E 5i 4.4 04 -r po(�S • 32-r- 6 /2 - �'l�.4-.A1• %Zoning District // <br /> 0 <br /> This project is a new . S16 ,4 re k ocit.,,..;+4i,t ^44+ Permitted Use? 9.9 This project is an addition/alteration to an existing building or structure. /d <br /> SANITARY SERVICE: , / PERMIT NUMBER: Rural ' ••. <br /> EWER J`�/1 26 EPTIC (new/; ' • I v\ // <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) C'— <br /> Wetland/Floodplain/ t/ / <br /> -- /3 <br /> Shoreland (attachment)NA- <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR/ { ErosionControl permit <br /> .! 4- /4- q2„ 1 TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, // <br /> 2ND FLOOR:,\c ` 3RD FLOOR: / 9 filling/access) �� , <br /> / �� ��(� / /=1 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -10. -I. .-I. •-•• Q and available options. <br /> (Please round to nearest dollar) •p <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? RlYes [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 0 Pont' know <br /> 7. Is this to correct a violation? [Yes po <br /> • <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -i -i <br /> 545-112 0/08) <br />