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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 5 1../4TER 171 E !`7. E12tC N ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> tOZ.('1 CUU 1JTY RD 11 (fftzornANIE 1 WI 535GpO Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> &o9- 3 -213 Z (cj 9S - Zl 3 z SATE At)I / (F CvWh+ii-.COM Li Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 51..4lER t)6DEt1c1 5 Lb}'fEl2 'DI Et E2 jC 14 ❑Site Plan including location <br /> AGENT ADDRESS �) CONTRACTOR ADDRESS of well/septic <br /> (City,I O ZLo C W.IN 1i b ft (City,state gip)� rrk) R) y El Setbacks <br /> MtkZ.INAANItE I w1 S3S(,0D MttiOYY1111■(F_ t wz 535100 <br /> PHONE PHONE ❑Site Plan approval from <br /> (000-4/8q — 21 32- (.120B - 'f 34 —2.13 Z applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 'I P. .161)E—R-14-11 4 _u 4 .CO Wt ' :I . 1611)EIZ Of • 41 /L,Grvyl ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ri NUMBER ©GIO(P 97a �� \ n 1 5, 9i041 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> (y ZO nit 19-7.1 16 '/4: +/4+/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 10241 Guy WIV Rte <br /> ❑ <br /> CSM: LOT SUBDNISION BLOCK/LOT Sanitary permits <br /> O(.4 2) 3 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S/aRfl C-t E Sti-E 1) C oAisneUCTL OA) ❑ Zoning District <br /> . <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> [)EWER TekEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LE S S 7?YR Al 30 f4.67- 0/4E ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> T <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: .---1 <br /> ErosionControl permit <br /> Al I 3 zoo 1 TOTAL SQUARE FOOTAGE +, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ^,200 filling/access) <br /> ✓( ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: @ 35.1 coo <br /> available options. <br /> -► <br /> (Please round to nearest dollar) $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes Ilo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres Jo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ao <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) Ekes Do ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes (D( do <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —to. <br />