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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME . 4 Je-Ad6REss.� Lt v'i rt`eU,1 Ic\�— ❑Zoning Status;CUP; <br /> �/ / Num ___. Zip) Deed Restriction;CSM <br /> 54/ I I 4 (C.Se y' 1 'f �j , WaUi'tgAee ((A 5��?7 Variance # <br /> HOME PHONE C PHONE 'TE-MAILADDRESS I ( ) <br /> ./:/C ) 1-1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME /�/� CONTRACTOR NAME <br /> S c%1 Moil►ors rj c a ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> IOEM/' L+y /wYA <br /> (City,State,Tip) (City,State.Zip) ❑Setbacks <br /> W14- 1-(.,re to C, 'f 535 '72 <br /> PHONE PHONE ❑Site Plan approval from <br /> 608 •-2 it/-37/2. applicable township. <br /> E-MAIL ADDRESS / E-MAIL ADDRESS <br /> on e S/ lue- S Q Ct.Gwc'.cco ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PPA�RCE NUMBER: CURRE ZONING: ACREAGE: ❑Elevation of property <br /> ❑ <br /> NUMBER 05lo jogce--22y-gi 70-3 �-1 , . ,�� ter.�/ 3 frontage drawn to scale. <br /> TOWNSHIP: /� / SECTION: <br /> r/h-f l) 2.2— v.: Aj' 1/a14: SE ❑Driveway permits <br /> ADDR'NI J�i / T r� (state,county,town) <br /> / `(�1 /`Cti(e Q4 C4 / k L I� i 5 (P vrl�?€ / - i 5.35q/ ❑Sanitary permits <br /> CSM: ._y�� Lo G SUBDIVISION BLOCK/LOT (public,private) <br /> l <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PR CT SCRIPTION: <br /> Cc r ov i v /E- 1 -■.j oicv) c .cd(f l o r\ ❑ Zoning District <br /> . ['This project is a new building or structure. ❑ Permitted Use? <br /> lit his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> SEWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> 171 5 / ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> Z_ 0 1 ' TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 1 1. filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2- _ <br /> l 0 ❑ Review Location,Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) 7 L)c�C� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes [ io ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Ekes Kg o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dees ! o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 2 o <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 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes to <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -i -P <br />