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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 /> Illik I'eh I' Pic)P e ("41 e S ,Zoning Status;CUP; 4^/ <br /> OWNER ADDRESS (Number,Street,City,State,Zip) (� p Deed Restriction; CSM <br /> �� �- ` 0� `�— Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6084t</L/ as 23 - Glave`4fcbe.40(`sln '-Q ,1 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions 30 <br /> AGENT NAME CONTRACTOR NAME <br /> G v--f ICO'bxe^k igSite Plan including locatio <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> �.1`?'1 vin` Air()(..`v. <br /> (City,state,Zip) \ (City,State,Zip) 1,gf Setbacks I,p 3/3 0 (°A <br /> \a C:c'so-r-- 537( °/ <br /> PHONE PHONE gSite Plan approval from . / <br /> to 0 F 1-1'-t,-1 1-1'-t,-1 x - � <br /> applicable township. /�/ <br /> ti <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> o(a�e Orn ko,,k ef P f1 y=% *rz K1 Floor plans to scale <br /> ,, <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) + g <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: II Elevation of property <br /> ❑NUMBER D7O0- 30./" 96 k —a- ( 1 0 X frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 0114 �,,� 3 y 1/4: -S E 1/4'/4: S 0Driveway permit <br /> ADDRESS: (� (state,county, <br /> $al ')-- MI°t�°w." 1CP1 l Sanitary .= ::;ts <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public�! . '1 <br /> aos (o <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6 f, ,::: cc r- ,rra e Zoning District A — <br /> his project is a new building or structure. 7 <br /> Permitted Use? .0 ' <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural r s <br /> FIEWER 104EPTIC (ne 'existi <br /> HEIGHT IN FEET: /9 NUMBER OF STORIES:: (Not including basement) <br /> 1Netland/FlOOdplain/ <br /> Shoreland (attachment) 1�,�- <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) rosi£tnControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 3O x y /0 2 0 4,, TOTAL SQUARE FOOTAGE: (Slopes,disturbance Urbance, <br /> T filling/access) <br /> 2ND FLOOR: 3RD FLOOR: /Pa <br /> gReview Location Survey A <br /> ESTIMATED CONSTRUCTION COST: $ /'/ 2 U v and available options. /�J�/) <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ l� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 17110 ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes to ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 'es ❑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) / es EINo ❑Don't know <br /> 7. Is this to correct a violation? . es Ilo <br /> S / CO 2 6 , APPLICATION MUST BE SIGNED <br /> (Continue on Back) -o ■ -+ <br /> 545-112(4/08) <br />