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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 /> /(//,4 'L /�/ Uf/i 1 M 544-40.0e6 ,57/W�E 4FtiZ /Zoning Status; CUP; C " Z- <br /> O NE/RADDRESS (Number,Street,City,State,Zip) / / o Deed Restriction; CSM SI6'� <br /> 3/�� Loet /vic trio J a/ 535_582 Variance(# ) <br /> HOME PHONE CELL PHE E-MAIL ADDRES9 <br /> '..y "/-7te.Z j;-; ;- mlc/i(ebu i---49 col, Cam'✓! ZSite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / C <br /> /)CH/KL /�/ 19/HA Site Plan including locatior( <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Say Lids gee 3 D/%° <br /> � <br /> (City,State (City,State,Zip) Setbacks <br /> � 1 �U9! 3 55g <br /> PHONE PHONE Site Plan approval from A/4— <br /> g - ',Y3 V- 7575 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> /A' Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: EIlevatlon of property <br /> ❑ <br /> NUMBER <br /> PARCEL <br /> 2//'--712-'- Y/4.0-0 �. — Z 3 / V frontage drawn to scale <br /> i <br /> TOWNSHIP: <br /> C 6 F/ G SEC ON: <br /> 1/o: A/ki 1/1/4: Si,/ Driveway permit <br /> ADDRESS: (state,county to) <br /> CSM: LOT / SUBDIVISION BLOCK/LOT Sanitary peril SUBDIVISION <br /> / /' V (public,,.1 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 3 D ,. /0 l X /C) / S 4 O is S7 C <br /> ` ,f Zoning District - <br /> This project is new b� uild or structure. ? ��'�/ <br /> Permitted Use.•❑This project is an addition/alteration to an existing building or structure. ii-A. . N■ S¢f ,- Z190 '/ <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address D i^ <br /> EWER Z E P T I C (ne; - �. /` <br /> HEIGHT IN FEET: /0 NUMBER OF STORIES: (Not including basement) Wetland/Floodplain/ Xi ,� <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> — ErosionControl permit <br /> BASEMENT: 1ST FLOOR: i e <br /> 3/-,f, mac,- 1 TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: I! filling/access) �P� <br /> DO <br /> AReview Location Survey I <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. �' h <br /> (Please round to nearest dollar) $ �+ <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? ❑Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance •- ' '•• -••eal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No nDon't know <br /> 7. Is this to correct a violati n? <br /> '2 ❑Yes ❑No <br /> 00 <br /> 0� APPLICATION MUST BE SIGNED <br /> t- /(Q (Continue on Back) ■ -4 -► <br /> 545112(4/08) <br />