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ZONING PERMIT APPLICATION Www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNERLNAI4E <br /> 2 r'ne' LL ping Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2/7-z 1-104/ ht/h 6f4itam WI S3?-17 Variance(# ) <br /> HOME PHONE / CELL PHONE MAIL ADDRESS <br /> '2 t -2 r'' t t u\0 a.A4err"0 Me S'tM 121<te Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AG AT NAME . CONTRACTOR NAME <br /> '<Pr) WCt In Atka& De.s(ph /'(omes tic Ite Plan including location <br /> AGEN ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2e(7-2 k Ay in di 2970 go/gm <br /> (City,State,Zip) (Ci State,Zip) <br /> etbac 6+ckbug W l 53 -l( WI 5331)P <br /> PHONE <br /> PHONE ite Plan approval from <br /> 1.708 13g- 2 (PD$ ((3 - 217-6 applicab a township. <br /> E- IL ADDRESS .�,..±A E-MAIL ADDRESS ��`� <br /> e 0.h a, a t /'1001e,S•(y' • ;, (TC,\f1taleS, qg oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://aco:essdane.co.dane.wi.us/) <br />• PARENT PARCEL NUMBER CURREN ZONING: ACREAGE: evaion of property <br /> NBER 07a ,361 `/GI c7 P V <br /> A-I 0. Si3 frontage drawn to scale. <br /> TOWNSHIP: f SECTION: <br /> m1 "LeD r) '/4: '/4'/<: riveway permits <br /> ADDRESS: c (state,co nty,town) <br /> Suq, WR-l L 4 �'r nitary permits <br /> CSM: LOT 6 SUBDIVISION BLOCK/LOT <br /> h�P 6> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: r-, -_^ I- <br /> sir1 r air (�y rQS(cL n4 o,J nr“..) home. ❑ Zoning District <br /> . Sfthis 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: LI Rural Address <br /> EWER KEPTIC (new/existing) <br /> HEIGHT IN FEET: <br /> 3 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 /> BASEMENT: 1 ST FLOOR: r--) ErosionControl permit <br /> 2 ej Y0 '3/ Z ,, TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> Z filling/access) <br /> 2ND FLOOR: Z 3RD FLOOR:22 `o 1 5 y f ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --0. -0. --► —0. /)�/000 <br /> and available options. <br /> (Please round to nearest dollar) VS <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 aiNo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Stes • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ONo <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 • o ['Don't know <br /> 7. Is this to correct a violation? ['Yes ►�1 0 <br /> F <br /> ,, ' \ _�(� APPLICATION MUST BE SIGNED <br /> 545-112(4i08) ,./, ‘ (Continue on Back) —0 —0 <br />