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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> o ME- ,' - ‘603 .• <br /> h'�""' oning Status; CUP; 4 1 <br /> O ER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> HOME PHONE CELL PHONE E-Iv1f�ILAppRES ���� Variance(# )� ' // <br /> •Il •g58 ii! a Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions I, <br /> AGE „T NAME CONTRACTOR NAME <br /> 'Tom KtLh4 ,FA Site Plan including location ■ <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> q5,/ WE/V' id <br /> y /' 0 <br /> (City,Slate,Zip) v (City,State,Zip) Setbacks (9 3 3 /50 Po <br /> 1iuod#) Or, .5-3 513 <br /> P NE PHONE Site Plan approval from a <br /> 4,5 ) 3s ' 12 S 1 applicable township. /t- <br /> E._ AIL ADDRESS ' cb � <br /> E-MAILADDRESS <br /> NIlSb o K Floor plans to scale . <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of PARENT PARCEL NUMBER: CUR property NT ZONING: ACREAGE: p p <br /> ElPARCEL ��/ p frontage drawn to seal <br /> NUMBER Qt1/Q?it.� "�` —idol d t... . 41 1 1 T.i 9 I g <br /> TOWNI-IIP: / SECTION: / �(i /Le ,.7� Driveway permits <br /> ADDRESS: ,1� , (state, county, ow ) <br /> 212. (Jb�L 1�'J • ►J� VJ w �3�L7 .Sanitary •- . its <br /> CSM: LOT BDIVIS N BLOCK/LOT <br /> (publi• priva e <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW `,'' <br /> PROJECT DE IPTION: <br /> 2 District , <br /> fôrfØu t�B LS /10 �K l S� f/ %Zoning A_/A <br /> . El This project is a new building or structure. ,v permitted Use? y" ' <br /> . ❑This project is an addition/alteration to an existing building or structure. <br /> RuralA• <br /> SANITARY SERVICE: PERMIT NUMBER: ,' � G4 <br /> r)EWER SEPTIC (ale /exist • , , <br /> HEIGHT IN FEET ■ NUMBER OF STORIES: (Not including basement) <br /> / it• , lood•Jai 1 <br /> ,S1 ore a s• a =chmentj <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: Eros IOnContrOl permit? <br /> /6 S ,, TOTAL SQUARE FOOTAGE: ,, p(.61904v**15100,; 1 <br /> kifilftng/access) , ` � e C <br /> 2ND FLOOR: 3RD FLOOR: /6 10 1 , t�, ; <br /> /V/ Reviewaocation Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ ��� D and available options. 4- <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? Lives No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes EIGo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? s ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Lives [3lo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) Lives l7 Vo QDon't know <br /> 7. Is this to correct a violation? Yes [iIGo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► -♦ <br /> 545-112(4/08) <br />