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ZONING PERMIT APPLICATION rluww.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ` , <br /> JEF-FIle l! AND SUSRN1 RAE-,V ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> PO 12O 1t 41,-1 2—' MAN.SON , W I SS NI I Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADjO SS <br /> € 57" 1550 J e i e, kaci realest -com ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME I 2I CONTR'CTOR NAME <br /> IGk-\ E. I�,cl�.�{ ol-sons Took) L -onsC4kP,, 61 //UG, ❑Site Plan including location <br /> AGEENT ADDRESS CONTRACTOR ADDRESS t of well/septic <br /> 3S 10 rlonl r— -D. <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> t/r OAJA , w( 555/3 <br /> PHONE PHONE ❑Site Plan approval from <br /> 6o21 — gyi _ 61/01 applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> paVt ® olsan fowl. c.osi E Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:f/ac:cessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL UMBER: /� / CURRENT ZONING: ACREAGE: <br /> El NUMBER 0343 oloSr32f-T054-o N—' l ,q lwe, frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> M i1 D i-&TON 1/4: 1/41/4: ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> 15o9 FL-ion) L A v p..,0 J A (01 535q 3 ❑Sanitary permits <br /> CSM: LOT I SUBDIVISION BLOCK/LOT <br /> G M0o1u RO. gsTT6 (public, private) <br /> PROPOSED PROJECT INFORMATION ` STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> I J cyZ.oU1)0 SU)/ kf,l4/It/C4 fa)L ❑ Zoning District <br /> . EIThis project is a new building or structure. ❑ Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER REPTIC (new/eXiSting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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 /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: G H 7 <br /> ❑ Review Location Survey . <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ and available options. <br /> -+ —'(Please round to nearest dollar) S O/ 000 s 00 <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? ❑Yes ENO ❑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? ['Yes ❑No <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -+ -+ <br /> 545-112(4/08) <br />