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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> n ille�n hO/- Zoning Status; CUP; <br /> OWN R ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 62 ti� M�� Si' , Ci rG1 f Vari nce(# ) <br /> HOME PHONE CELL, HONE E-MAILADDRESS <br /> 4- 2_75- tab 2z.S.--fev Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGcbff NAME i CONTRACTOR NAME <br /> 19t,r k zl,\ FU'k &. c'i�c n Ho(ieS Lit_ Site Plan including location <br /> AGEN ADDRESS 1 CONTRACTOR ADDRESS of well/septic <br /> 2c(3-z A v /72,41 24172 tit /71m <br /> (City,State,Zip) (Ci State,Zip) E Setbacks <br /> 64-Chbl. Lti i 5 y7-1( Liu/ 53 <br /> PHONE PHONE ite Plan approval from <br /> .� _ ' 4 2 ' applicable township. <br /> fob y �- �i✓�-� �3�- z��d <br /> E-h IL ADDRESS ,_ E-MAIL ADDRESS <br /> CUA 0 ini h^�edit i s-(civ C di Rt<loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acGessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:p� frontage drawn to scale. <br /> ❑NUM ER ���d ! 1316 0 /�{- I I-'Ol0 <br /> TOWNSHIP: !j/p j.� SECTION: <br /> 1 O 1 C D t� 1 4: '/4'/<: Driveway permits <br /> // "'K. state,county,town) <br /> ADDRESS: 31 UP <br /> 0rlCS Lf ❑Sanitary •- is <br /> CSM: LOT SUBDIVISION BLOCK/LOT (publi , private <br /> Ki 1S SOW -i <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: S ` �� 0;1,0 'A_rE. ,V <br /> n� ���( �, �� � �n� (I�; ,L,�V�Loning District <br /> . his project is a new building or structure. Ly Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ R at Address <br /> EWER FIEPTIC existing) <br /> HEIGHT IN FEET: 0/(2. ) NUMBER OF STORIES: (Not including basement) <br /> ilq ❑ 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) ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 213 14 ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> �� O filling/access) <br /> 2ND FLOOR: 3RD FLOO C-0571 <br /> (s J' V ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ $ 2 5 and available options. <br /> ,. <br /> (Please round to nearest dollar) $ J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes EiNo UDon't know <br /> 2. Is there a wetland or floodplain on or near the property? 01'es o QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? 1'es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes 1iNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le blank if none) <br /> 6. Is a location survey required? (see reverse) es No QDon't know <br /> 7. Is this to correct a violation? DYes No <br /> / <br /> - •■{,-. <br /> (� 1 _� APPLICATION MUST BE SIGNED <br /> �� -.- (Continue on Back) -► -+ - <br /> 545-112(4/09) <br />