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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App U <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0 NER NAME <br /> - <br /> b`j Y^ <br /> paining Status;CUP; <br /> O`WE'DD E arc , �� �5�- �Ur S3S3 z Deed Restriction;CSM <br /> M <br /> Variance(# ) <br /> HOME PHONE CE L HONE E-MAIL ADDRESS <br /> ,1)i� 1 41 ./ A ' L..i 1 ' # 'Li 1' Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION And includes dimensions <br /> AGENT NAME l�, / COT C(TOR �'( �j /�/� <br /> �1 (S l t V\ 6�, � _. l� Ss∎�.l 1 11Y oli I t� i Plan including location <br /> AGE`VTADDRESS TOR rrti-u o welUseptic juilAvvatc. <br /> r zr , rt(City,State,Zip) etbacks <br /> AC r , fir, '\11A sacci 7 <br /> PHONE 4to Plan ap val from <br /> �j Q�(f� p .'p icab ownship. <br /> tU ') Dcj - 110 <br /> E-MAIL ADDRESS E A�AQD i;-, <br /> 1 Jl' /I�.tj r $ mil' ,, ►'41 or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> PARENT PARC N M ER CURRENT ZONING: AC GE: <br /> ❑PARCEL D{ (\ I 0-( 3_SOO Q I frontage drawn t e. <br /> NUMBER 1 (J000 ���JJJ"'lll [JIJIJ J � <br /> TO SF, <br /> y4. ��4��4: " �� 4;1-Driveway rmlt$ <br /> ADDR ss: �� ! 1 (state,cp(mty,town) <br /> 4i c A 1 rsol 0t to <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION F REVIEW <br /> PRO ' SCR• ION: <br /> g 1 I • I ./ .. r. • • mg District <br /> . This project is a new building or structure. • -ermitted Us: <br /> his project is an addition/alteration to an existing building or structure. <br /> S ITARYSERVICE: PERMITIIU6f2zt ❑ Rural • '' <br /> EWER PEPTIC `/ll �l`l (newt xisting) <br /> HEIGHT IN F NUMBER OF STORIES: (Not including basement) <br /> 71 \ ❑ Wetland/F ...plain/ <br /> DD AREA TO NEAREST SQUARE FOOT: ShOrela (attBCh i <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) Eros •nCon u•• permit <br /> BASEMEN : ^ 1ST FLOG-: . <br /> �U( + TOTAL SQUARE FOOTAGE: 4 (slopes,di- rbance, <br /> �•>rilts�. + filling/a ss) <br /> 2ND FLOOR: 3RD FLOOR: i vs �r r �r <br /> l/ IT ❑ Revi Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ (fQ I and available options. <br /> (Please round to nearest dollar) l/ l.� 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Rio ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 4o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? E Yes D to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes ViNo <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) Ekes 10 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Rio <br /> 1/ Q , C,) <br /> APPLICATION MUST BE SIGNED <br /> 545-112 W08) 2 (Continue on Back) <br />