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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 /> 1d lir L.rp PJZT/le- P ! w to c c TQ mry y ❑Zoning Status; CUP; <br /> WNERADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 55F5 ' Jc c - Rd.. /I-4x o fivxtn, Lam• . _;--3._ -6,0 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> S .'. 5 - 'A', - • - k. c. __ , . ,jq❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Larry ! �c)t e r ❑Site Plan including location <br /> AGENT AD66R_-ESS CONTRACTOR ADDRESS of well/septic <br /> Sses rn ctiaciti.r RA . <br /> (City,State,Zip) (City,State,Zip) ' RECEIVE) <br /> PHONE PHONE ❑Site Plan approval from <br /> 795-- 1/9 y(Y FFR 1 1 apg6abletownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dtane.wi.L I) &p PENT <br /> PARENT PARCEL N MBER: DDt��� CURRENT ZONING: ACREAGE: ��CV IOn Oproperty <br /> ❑NUMBER 000 ogo& .-j 91 aa2-c A / d 3 '- f frontage drawn to scale. <br /> TOWNSHIP: SECTION: ' t—.� <br /> Hick ,�- - iv/� '/a: , ✓L 1/41/x: [' Driveway permits <br /> ADD ESS: (state,county,town) <br /> cc65 mt a tr �A. �'A-�.zG mukte, lx.y i 5 3.56U ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: /� <br /> Pptt. �I„f it of /'DI Aou y eAtractrvy► 4- .tc+racJ. e1 S040 ❑ Zoning District <br /> . <br /> This project is 5 new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER r)EPTIC ' (neW/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI 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 /> BASEMENT: 1ST FLOOR: <br /> Q ErosianCOntrall permit <br /> .3000 (slope's TOTAL SQUARE FOOTAGE: , (slopes;disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> .3000 <br /> LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ �� O and available options. <br /> (Please round to nearest dollar) "'∎ ♦ ♦ ♦ ♦ ♦ Q Q <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes �f No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes IANo ['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(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 70No <br /> AT BE SIGNED <br /> (Continue PPLICATION on BackMUS) -* <br /> 545-112(4/08) <br />