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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNEF NAME/.1 <br /> Ksie " e QFe t'ce ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Numb,,r,Street,City,State,Zip) // Deed Restriction; CSM <br /> tiQ/ 3 'Cy Ore Tea,` "de( 65'!- S3 5—Co Z Variance(# ) <br /> HOME PHONE / CELL PHONE E-MAIL ADDRESS <br /> ,o ('' 13/-37?f" ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ,,�A CONTRACTOR NAME <br /> /1,•� /4 -- (,P,te5i 5 AC-46`a,...c ,.tom ❑Site Plan including location <br /> fin` AGENT A2i DRESS //n, CONTRACTOR ADDRESS of well/septic <br /> '` ,J q'0/ t�'t,-• lb, q ,/ 7 •�tr: � c�i-- <br /> (City,State Zip) (City State Zip) ❑Setbacks <br /> (:4Qij i/�ad k., , 513 7/h !'�adi , � .5 3?/ <br /> ` PHONE ' PHONE ❑Site Plan approval from <br /> \Y �k. 2 S—,, .// : 6a k' 20Y— flit r' applicable township. <br /> E-MAIL ADD!ESS E-MAIL ADDRESS <br /> kev:r■ / ester SetC74.:'-s- : ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.daACREAGE:ne.wLus/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: <br /> ❑PARCEL NUMBER 05(o/oW _rTj7'On?_i pcPfez 1 /,/ frontage drawn to scale. <br /> TOWNSHIP: 1.- <br /> d SECTION: / <br /> Sne-�n :e 1/e: 1/4�4; ❑Driveway permits <br /> ADD ES (state,county,town) <br /> L71, r-( ira,j ,.rab'h4,, c..s 5-32To Z <br /> CSM: LOT SUBDIVISION !BLOCK/LOT ❑Sanitary permits <br /> Cif g<I/ 1 / 7 (public,private) <br /> PROPOSED PROJECT INFORMATION 'STAFF REVIII <br /> PROJECT DE RIPjTION: IN,gg <br /> cure Z. T U Zoning District <br /> ❑This project is a new building or structure. U Permitted Use? <br /> y3This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER. U Rural Address <br /> EWER )4EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /0 f © Wetland/Ploodplain/ <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: 1ST FLOOR* © ErosionCOntrol permit <br /> Li 0 3-7/ -' + TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q� and available tens <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? Lilies EINo niton't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies ❑No 0 Pont 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 D to <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# IS-91 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes E4No ❑Don't know <br /> 7. Is this to correct a violation? es ❑No <br /> v APPLICATION MUST BE SIGNED <br /> v (Continue on Back) <br /> 545-112(4/08) <br />