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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ` / c —I <br /> -)T eV V It v w'01,1 _ Zoning Status; CUP; <br /> OWNERA DRESS ( Zi Deed Restriction; C <br /> �� i e UPC��t--,'se�� �� �3�3� Variance(# Z5 y 2—) �rc'J <br /> HOM 'HONE CELL PHO E E-MAIL AD RES <br /> di V <br /> _ <br /> i — to. f r. Sol>me �an�s hang/ytayseroce. 'vrta'/.C°ryt 'al Site Plan drawn to scale A e, <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimension / ! <br /> AGENT NAME CONTRACTOR NAME <br /> inSit- ' -• = luding locatio 2,r <br /> AGENT ADDRESS CONTRACTOR ADDRESS of -ell/septic <br /> (City,State,Zip) (City,State,Zip) ;0.43 Setbacks ,,5-2/C° 0C/ <br /> /O/0 <br /> PHONE PHONE ,Site Plan approval from ,VA <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> a�ci Floor plans to scale / <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property / <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAG v <br /> ❑NUMBER Nil l —/q/-/— 'Q c — / Q, 2 '6�, frontage drawn to scale. <br /> TOWNSHIP: © / r sECjlgNy �/4. /) J , , �/ 6 Driveway permit <br /> T J' /4/4: (state, county, ow. <br /> ADDRESS: <br /> Ct '� /,Sanitary •- -•• s <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, Mis <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / f <br /> 'Z - y �. , (Z C a y- f 6 r gZoning District C <br /> / <br /> 19�v <br /> This project i new bulldin�or structure. . � ermitte se? <br /> p �rr <br /> ❑This project is an addition/alteration to an existing building or structure. C a -- <br /> SANITARY SERVICE: PERMIT NUMBER: Rural A•• -ss <br /> FIEWER 14EPTIC (ne e01110F0, <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ' � <br /> / r).. J � 'i <br /> ,.� Uwr:rr .odplain/ <br /> / ` horelan• (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: ti .ErosionControl permit' /j <br /> Z 7 ,, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, `a <br /> 2ND FLOOR: 3RD FLOOR. filling/access) 4/2i� <br /> 2 6 if I, Review Location Survey ir <br /> ESTIMATED CONSTRUCTION COST- yzy/ D`� and available options. o� y Please round to nearest dollar "♦ "♦ "♦ "'� ♦ -► V <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? Dies ❑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? DYes ENo <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 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> fi(S T rx S F J 2_ 6 3 Z �o f APPLICATION MUST BE SIGNED <br /> 0 3 & (c Fn l y y 1 2._ (Continue on Back) —► —► —► <br /> 545-112(4/08) <br /> ---,,E4__ <br /> pt. 53 0 -7_6 V <br />