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F <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> PAIE'l a .Z. U 4 er 0 Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> L 4 // V 14 d C)ee 60.v t e.JT 5 3,525' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6 vL-3y — 11'941 I da r i r-' 6 iert- - Ada , c:.v.,+-i [Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /-7-1-,"/ U /e,- 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 90 L¢ La ti y /2o•i <br /> (City,State,Zip) (City,State,Zip) [Setbacks <br /> Ote9I3 ,) , LAJ,y 6:3576" <br /> PHONE PHONE [Site Plan approval from <br /> 6.0 k - 3 y-7.-- 5!S/p "' applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> d //er g eeb3* Q ,4 I/ , ea,'" 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG <br /> PARCEL `3 Q 14' .5/ frontage drawn to scale. <br /> NUMBER £)4jD^2�/-3�.'. `/ !�` /7 <br /> TOWNSHIP: P (/�, SE�CJTION: ' S Z& '1 i 0 gib,I: [Driveway permits <br /> rJ� 4) Nu0A.1 IV 1,3 �4: N 4 IA: <br /> ADDRE� � (state,county,town) <br /> L ct II7 1c>cl o pe G 1...)..i. 6'357 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 2/78 / (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> N E 0 /-/b a Se. ❑ Zoning District <br /> . [iThis project is a new building or structure. ❑ Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER (EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ` ❑ Wetland/Floodplain! <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: 1314),`‘-h 't1' i 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> /79 Z 2'43 zi/ _4/..41.e._ ! filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Ms' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) '♦ ♦ '♦ '♦ -+ -* $ Z 2 S a ov <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes no [Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes [ io <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 IRINo DDon't know <br /> 7. Is this to correct a violation? [Yes [ to <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -. -► <br /> 545-112(4108) <br />