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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 /> /A° Lej ❑Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,StreeYCity,State,Zip n /� Deed Restriction; CSM
<br /> //s, ,,-,7294,,„y' J J/F'E'��.r'l� J� � 5 Variance(# )
<br /> HOME PHONE CELL P ONE E-MACIADDRESS
<br /> ?.o-v'/d `/e-137 4,.u,c j�s3 6 4 �/Iv/rte.//40440 Site Plan drawn to scale
<br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT IAA E / CONTRACTOR NAME
<br /> . /z / C o .:. 42 �o r p• ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTO DRE�SS of well/septic
<br /> 7 O/ tC;n, AO;0 /0 /9()
<br /> (City,State,Zip) (City,Stat Zip) p ❑Setbacks
<br /> ,D(: 13, 12, /Z3 ./? Ve/O ri , / 557 2.i
<br /> PHONE PHONE ❑Site Plan approval from
<br /> OS 770 OS'-,-� k o - /5' Y766) applicable township.
<br /> E-MAIL ADDRESS E- I LADD S�
<br /> Ct c„a �c." , 7
<br /> a/,,i,d1 c ai ❑ Floor plans to scale Ze..c, / c/a 4,,,,d,�, c c.)*
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:
<br /> ElPARCEL frontage drawn to scale.
<br /> NUMBER Q Z 12--321-8900-O £M- I
<br /> TOWNSHIP /J A SECTION:
<br /> U/ee-e C'< i 1/4: 1/41/4: ❑ Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> /if /4 "''r /1 ,e'e r/`M, �x `5_,`i S 7 ❑Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> t 0(o'7S / (public, private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION: v
<br /> fn x /1/ // /,/�/vr e,)- /,1<,.-,5 LI 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 /> SANITA SERVICE: PERMIT NUMBER: LI Rural Address'
<br /> ,// J)EWER PEPTIC (new/existing)
<br /> HEIGHT IN FEET: , NUMBER OF STORIES: (Not including basement)
<br /> a /6` / ❑ Wetland/F000dpiain/
<br /> Shoreland (attachment)
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> ❑ ErosionControl permit
<br /> BASEMENT: 1ST FLOOR:
<br /> �----' /1/ /C/l 1 TOTAL SQUARE FOOTAGE: j (slopes,disturbance,
<br /> filling/acceSS).
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> 71/ 2-'} ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q� �n and available options.
<br /> (Please round to nearest dollar) •p O C)
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1116O ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Y Et o ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ❑N
<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 one)
<br /> 6. Is a location survey required? (see reverse) Elves No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes t to
<br /> N0 L I'J&raCe—j
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) ■ -► -*
<br /> 545-112(4/08)
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