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ZONING PERIVIT APPI_JCAT I ON ww countyofdane.00m <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> VV t�� 'O'" r '�'� Zoning Status; CUP; <br /> OWNER ADDReSS e,Zip) Deed Restriction; CSM <br /> �D 36 1 Osso.�. S�e�n s(�T %lld [ei, W Z Variance(# ) <br /> HOME PHONE CELL PHONE (GeV' E-MAII.ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT ME CO OR N E <br /> G/I( 4c 9O/'f i ,,,t Site Plan including location <br /> AGENT A DRESS CONTRACTOR ADDRE of well/septic isie <br /> (Cit State/Zipl c.31-4, (City,State,Zip) El Setbacks <br /> PH dE • e PHONE 0 Site Plan approval from <br /> b$ S1,5--- 6 (0c, I applicable township. <br /> E-MAIL ADDRESS I E-MAIL ADDRESS <br /> ,vta.-tel.... ,015&- t. ei-CF ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL UMBER: CURRENTZONI ,A ACREAGE: p p y <br /> PARCEL ��^^ pp CURRENT <br /> 1 /. / frontage drawn to scale. <br /> U NUMBER OJ( 0860 ' I Z'�G�I"0 co <br /> TOWNSHIP: SECTI <br /> cc e • ? ( 1/4: PE 1/43: ,\ 0 Driveway permits <br /> ADDRELSS: C J 1 v�+ (state, county,town) <br /> Sb3` SPe",,.5 /655 d . l SUBDIVISION i f 1 BLOCK/LOT L ❑Sanitary permits <br /> csM: <br /> I Ktu o 2:1 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ! <br /> / 8 1 � �S✓o.�.-.vi s-.,.,,...,„„r,} ... ❑ Zoning District <br /> . EIThis project is a new building or structure. " <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: i PERMIT NUMBER: ❑ Rural Address <br /> DEWER PTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> U 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: ErosionCOntrol permit <br /> ' 7 19-0 j, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ( 1 filling/access) <br /> / 2-0 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) 2,0� D 1.A,-,$--N../, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Wes Dia Epon't know <br /> 2. Is there a wetland or floodplain on or near the property? 111Yes Vo DJon't know <br /> 3. Have you talked with the township about your project and are they in agreement? !Des Flo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ''es alo <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) Des * o QDon't know <br /> 7. Is this to correct a violation? Yes 0 <br /> APPLICATION MUST BE SIGNED <br /> ..; (Continue on Back) <br /> ^.d5-I1)id/CJA )6 <br />