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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0 ER NAME /� <br /> 4 q b/ i Pro El- ti ('S Zoning Status; CUP; C <br /> OWNER A DREj (Number,Street,City,State,Zip) <br /> (10 77 ,/W f' n �i �35 a q Deed Restriction; CSM 26 <br /> ff y Ova Variance(# ) <br /> HOME PHONE / CELL PHON i E-MAIL ADDRESS <br /> OM-375-3`/y9 (pbg- 5- S-3'417 1esi4cc,r- org7�a/63- Ytgi /. co1 <br /> 14 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME p 6 <br /> 02Site Plan . uding locatio <br /> AGENT ADDRESS CONTRACTOR ADDRESS of <br /> (City,State,Zip) (City,State,Zip) gi Setbacks sod/v <br /> PHONE PHONE d Site Plan approval from /17, <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> >'a4 Floor plans to scale // <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) �levation of property �� <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL D Q/'D F Z 5855 C', - 0, (. frontage drawn to scale. <br /> NUMBER O U <br /> TOWNSHIP: SECTION: <br /> p V' C-�� C 7 IA: A/W 1/41/4: /0,0 PI , way permits <br /> ADDRESS: QOM, county,town) <br /> 5 ,-,s- , <br /> CSM LOT SUBDIVISION BLOCK/LOT It Sanita " ••ItS <br /> 3 2 2 0 2 (public, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJEC SCRIPTION: W,,� <br /> i 0 �,c.v- c / V�' c v c k 0 , S e-- Zoning District C- 2- <br /> . This project is a w building r structure. 2�O �`" <br /> ..Permitted Use? <br /> This project is an a ion alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural ' -. -Ss <br /> EWER PEPTIC (ne -xistin•I <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) , <br /> / WWetland/Floodplain/ A, (- <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes,dtsturbance, / <br /> // filling/access) _ 'jP <br /> 2ND FLOOR: 3RD FLOOR: ^ 40 <br /> ESTIMATED CONSTRUCTION COST: <br /> 14 Review Location Survey A,f� <br /> —► —P ♦ -r -► .- 3,S D coo, 00 and available options /1"� <br /> (Please round to nearest dollar) I gac s,L�/4 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Des ENO ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Des ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des ❑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) ['Yes ENO EDon't know <br /> 7. Is this to correct a violation? :Yes ❑No <br /> _C-2‘-�3?a 7( z ,5 ! ®0, 0 0 APPLICATION MUST BE SIGNED <br /> /� ! (Continue on Back) -► -4 -4 <br /> 545-112(4/08) C... Gt_,-4,,_ 2 6 / 3 ‘ gS ----> / -‘fir/ / 1/Oct. <br /> 0 <br />