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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU' OMER TO PROVIDE <br /> OWNER NAME <br /> r _ L_/ P <br /> E'Zoning Status;CUP; <br /> W <br /> ONER ADD- (Number,Street,City,State, p) <br /> // /6 s� Ho� sr Deed ha Restriction;CSM <br /> h� / Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .../04.-- 49 . -- "' -III -36=674 % ®Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 7/nor/iv 44xb LA bt '01, '7DtA, zoc., EZ Si Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> �CA Smrvk" 72,6 40119 ' ' �' ' <br /> ( ,State,Zip) (City,State,Zip) Setbacks <br /> I0 0 A1 o: _ a , if t, <br /> "ONE PHONE O Site Plan royal from <br /> .i48 °o2A°-/394 log 115.5-/3 g0 applica township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> /mw 7�a.yARod, , I ��i �.� Al Morocco/3'1 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of grope <br /> PARENT PARCEL NUMBER: CURREN<ING: ACREAGE: RI 0 PARCEL frontage draw scale. <br /> NUMBER d ■• -- © 4/ /-1,.,,,, .• - <br /> TOWNSHIP: SECTION: <br /> k T'-fi f O /g -1/4: /UC a) '/41/4:/V a.J ❑Drivew permits <br /> ADDRESS: (stat ,county,town) <br /> P/& .STS. ti7m'c ,E4 6 r D hO/t1 wr -53526 Sanitary ` <br /> CSM: LOT S DN�IS_I�ry BLOCKlLOT <br /> ® ry permits <br /> / �ill(J/YIO�V Ti (• blic,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /`—.gym i 1...tr i2a n') ,40Drr7o/1) • ,oning District <br /> . ['This project is a new building or structure. N -ermitted Use? <br /> IRrhis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUM E : k ❑ Rural A dress <br /> EWER gEPTIC gc k (f_ V\ (new/e 'sting)■HEIGHT IN FEET: NUMBER OF STORIES: (Not including basem ) <br /> J3.5.�. ONg, ❑ Wetland/FI plain/ <br /> Shorela (attach ent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionCo I permit <br /> SW?/ f� Cy 4 TOTAL SQUARE FOOTAGE: + (slopes, • turbance, \ <br /> r'�+ filling/ cess) l' t), <br /> 2ND FLOOR: 3RD FLOOR: v <br /> .360 58' Pr. ❑ Review Location Survey ' <br /> ESTIMATED ED CONSTRUCTIO NCOST: ♦ ♦ ♦ ♦ ♦ , � .Q� and available options. <br /> (Please round to nearest dollar) <br /> The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes Rtslo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes Ro ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? OYes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes a"Jo <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 f 1 o ODon't know <br /> 7. Is this to correct a violation? Oyes n o <br /> .,..0APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> 77. (Continue on Back) —• —Pi- -4. <br />