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. . • <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �,.�J <br /> -" `ME`r s " `f� os '�E-e Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) `/ Deed Restriction; CSM <br /> 18pC vl//�L/ ��� C.1J�G/rO/r, �/ .�3Jy Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> kg--.98 -'6e d''a.s72 'j &}/8/40 4 CDM Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ��J� <br /> AGENT ADDRESS �O•s, �' b) "" g4 Site Plan including location <br /> CONTRACTOR ADDRESS of well/septic <br /> .7%/14 CRP <br /> (City,State,Zi p) (City,State, <br /> Zip) ^ �/�/ /� 9 . �etbackS <br /> PHONE kf �7 i I1 iSa S'A <br /> PHONE Site Plan approval from <br /> 7/S—g"-3(14t3 7/S�5y._76 yo applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Tivl sg4r3@#9-b ,zo/N6y oil'eon' Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ElPARCEL 3 !1_nV- 002' -3 R. / 2/O frontage drawn to scale. <br /> NUMBER .J7 0� O�/ (J- v <br /> TOWNSHIP: • SECTION: <br /> ,C B l®N 1/4. .1/4-1/4. Driveway permits <br /> ADDRESS: /,' 1/100/31 � state,county,town) <br /> /a2 W//VD V/ <br /> Sanita •' <br /> CSM: LOT SUBDIVISION BLOCK/LOT ate <br /> (publ. ,private <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: • <br /> o7 27 � �ning District <br /> • R�6E 14/Y y1 Si s .D he ,_, <br /> This project is a new building or structure. Ly"Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER:� CI Rural Addr- <br /> W rI �N '" <br /> t ,EWER ER EPTIC (new . <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 11/lo "TQ k/�,(� / 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 /> /y 2/yF /9/ (DI O / j TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> /► filling/access) <br /> 2ND FLOOR: 3RD FLOOR: , <br /> W IW I_ Ale A/E O28d Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ 7Boo / and available options. . f <br /> (Please round to nearest dollar) $ /V <br /> 1. The property is within;300 feet of a stream or 1000 feet from a pond or lake? Efres gNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Tires ,No DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 1Y `,es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? fYes ,No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# I Li 01 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) QYes ONo DDon't know <br /> 7. Is this to correct a violation? ['Yes INo <br /> �\ APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -+ -+ <br /> 545-112(4/08) <br />