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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 /> ck),/N.L574-) 8 T-- Cr oning Status; CUP; <br /> NER ADDRESS (Ntumber,Street,City,State,Zip) Deed Restriction; CSM <br /> 6 7/' Gki m R`5 UJNY -,C,Q-i2, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Algg--iN ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ONTRACTORNA/ME Q <br /> A,uls-i`+l i S'171�t itS u,/t_ea,e5 ' e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3O.a 7 �-775tti Cass/P06 <br /> (City,State,Zip) (City,State,Zip)/.-1 <br /> PHONE <br /> cl �(A-t-k 1 <br /> NE ['Site a proval from <br /> g3 �7a appl' le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> b 5,b%.t _ 11 •, /�1 oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/) <br /> PARENT PARCEL NUMBER: CUR NT ZONING: ACREAGE: levation of property <br /> ❑PARCEL Cq 1) -3OO/ISO O J frontage drawn to scale. <br /> NUMBER - / <br /> TOWNSHIP: � SECTION: <br /> ,pD��,, <br /> [S7(5L 3 0 1/4: S 1/a1/4: ❑ Drive ermits <br /> ADDRESS: _� (St , unty,town) <br /> 6,"V �6g-� VI 1U P � "All—il -- ❑Sanit rmits 11�o7 <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub' rivate) <br /> B/ 15�d� CQ ,/ O <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> q Zoning District <br /> ❑This project is a new building or structure. [permitted Use? <br /> IE.This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBE A - R I Add ss <br /> FEWER SEPTIC 1 new/ XlSting <br /> /HEIGHT IN FEET: NUMBER OF STORIES: ,'of in uding basement) , <br /> �// 5--- 4 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) <br /> 1ST FLOOR: <br /> BASEMENT: _I Ero to ntrol permit <br /> j 1 TOTAL SQUARE FOOTAGE: (Si S,'disturbance, <br /> 2ND FLOOR: 3RD FLOOR: / .5-. ,.5-. , fillirlglaccess) <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -01. ♦ ♦ -.. PO �0' and available options. <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 2No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes ['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(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes No EDon't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► ■ -* <br />