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ICN( <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> -f"1`o TO - C/c Al4 c 74}/ZCl4 ❑Zoning Stau CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> -7 7 Z 4= �c�,v,,) ,-{v,/ A L.0( N 7 Deed ce(#fiction; CSf�I I <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Variagce(# j�j <br /> n Site Plan rayon to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includ dimensions <br /> AGENT NAME CON RACTOR NAME <br /> 6CO2�' C 1/L%jam- AJItt cs -cmc,(Ec,1/) G� ❑Site Plan in Iudi location <br /> AGENT ADDR S CONTRACTOR ADDRESS of well/sept <br /> /00( k= S7 ' /ea/ ` - Ne- f( S7 <br /> s(City,,State,Zip) <br /> / (City, te,Zip) ❑ SettfaV k <br /> \ u4k4 / h ,-,cf y k)` Ems-/ !Air 53f97 <br /> PHONE PHONE ❑ Site PI val ,AFTI <br /> 46 0 2l 2--? '5-C �l 00 applic hip. <br /> E-MAIL A RESS E-MAILADDRESS <br /> C Nut_ co f . cr - ,,.) A , Cr),�1 ❑ Floor p t�gat' <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation <br /> O ep;,y <br /> l PARCEL 05j- / 2.-1W-1 ----7\------7\-- i 4 7 frontage dr to scale. <br /> le. <br /> NUMBER <br /> TOW IP: SEC ON: <br /> -le-W7 C t� '/4: '/<'/<: ❑ Drivewa p y, w <br /> ADDRESS: �"' (state,c'ounpps�r,tt�wn) <br /> If 71(2 Cam%(./i)(y w�/ 4 0/Q, (,)( 5- 7 ❑ Sani <br /> CSM: L SUBDIVISION BLOCK/LOT <br /> OG16.c� / (pu t ) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: [� <br /> 4Dr SEiso,3 �(X'), AOD, 7ie-,, k)(X/( 4:vryej,)7 ❑ Zonin fist <br /> . fThis project is a new building or structure. <br /> ❑ Permltte Use? <br /> aTtiii—project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Addre <br /> 1W EWER SEPTIC SS 176: 7 (new/exi n <br /> HEIGHT IN FEET — • OF STORIES: (Not including basement) <br /> /<6/ C/ ( "�? L f CI Wetland/Flood9 in/ <br /> Shoreland'(attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions i cluding unfinished area attached garages and above grade decks or porches) <br /> ❑ ErosionControl permit � ll <br /> BASEMENT: 1STFLQQR: �/ <br /> Z (J G 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, ��( _ ' r <br /> 2ND FLOOR. 3RD FLOOR: filling/access) / lPd <br /> J� <br /> �,� ❑ R vi Cation Survey <br /> I' <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ _ -► ♦ ♦ ai al ble options. <br /> (Please round to nearest dollar) $ C.,// v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? FlYes a� , ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes RrO fDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑{es nNo� <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 ao ❑Don't know <br /> 7. Is this to correct a violation? EYes [ lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* - <br /> 545-112(4/08) <br />