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ZONING PERMIT APPLICATION www.countyoldane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 4(P011- 0 w.k n n 0 Zoning Status;CUP; A "/ <br /> OWNER ADDRES (Number,Street,City,State,}ip) n�� <br /> ��y S co'/G n c1 Deed Variance Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADD' SS r / <br /> d37-Ti 279 3 /1/ be4 to.,i,�.'.-.' Q hycc'co---7 VSite Plan drawn to scale <br /> VC AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions AGENT NAME CONTRACTOR NAME S /�'e f�± <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) lJZu Setbacks 70/0 <br /> PHONE PHONE Site Plan approval from ,�/ <br /> applicable township. /v/ <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale // <br /> / <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usl) Elevation of property <br /> PARENT PARCE NUMBER: CURRE TZONING: ACREAGE: p p y <br /> 0 PARCEL NUMBER 0/Z�p9/l-3�0�''3�Z- /4- ) /,./� frontage drawn to scat . <br /> TOWNSHIP: SECTION: <br /> .errs,,,l/ oc„,,il53G' 1/4: it/4"< 1/41/4: 5e— l<1 Driveway permit <br /> ADDRESS: '/ (state,count o, • <br /> (9 y7� 5eela"e/ 4 t'Sanitary p- 1 its <br /> CSM: LOT L1 IVISION // BLOCK/LOT (public, • ) <br /> 1 5(.4,07 //,‘ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �f / <br /> Stied Z- ( x l‘ 2( 1 , C Zoning District A -1 <br /> . _This project is a new building or structure. Rc-- S ,permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Ad• -�s <br /> EWER EPTIC (new may+'°-� <br /> HEIGHT IN FEET: ��JYY'��� NUMBER OF STORIES: (Not including basement) <br /> 3 / / 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 /> / <br /> BASEMENT: 1ST FLOOR: ErosionControl permit r <br /> 0 I 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, t(J <br /> 2ND FLOOR: 3RD FLOOR: •� /w G filling/access) �� / <br /> 30 y Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ y. .� and available options. <br /> (Please round to nearest dollar) TOO <br /> /! <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 M o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ['Yes M o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ►;d o <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) fres ['No EDon't know <br /> 7. Is this to correct a violation? Yes Elo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />