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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 /> S.2ihc AL,4 GA Sr gP 1/ 1e/ L va•- 124,J- 2L4/� . --r- ❑Zoning Status; CUP; <br /> OWNER DRES (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 7 9 q IA)es'-i- l]:1 ( C ,1 •C).�, Variance(# ) <br /> HOME PHONE , CELL PHONE E-MAIL ADDRESS <br /> 3 3 3 -, 041. 333—(y7 I i g , A , _ d '}'n l*-w ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CON RACTOR NAME <br /> p,1-0.( F ov-►s L1L ❑ Site Plan including location <br /> AGENT ADDRESS CO TRACTOR ADDRESS of well/septic <br /> ;_ii) --Tev y (t. S . 10, <br /> (City,State,Zip) (Ci State,Zip) ❑Setbacks <br /> J kfrl f r'e,1 r^i, WI 6-3s-0 <br /> PHONE PHONE j ❑Site Plan approval from <br /> 6'-����-7�7 .) applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ifh-04:14 61.,';` I 001„6.0 ryy ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARC L UMBER: CURREN ZONING: ACREAGE: <br /> ❑NUMBER 013j/ D 7i 11.- 1 - -c A-1 /., qg— frontage drawn to scale. <br /> TOWNSHIP: SECTI <br /> IdCII-C�� _ '/<: i/ L) %/e: ,511/ ❑ Driveway permits <br /> ADDRESS (state, county,town) <br /> CSM: 7q(eq LOT 04- /1'41 suBDlvlsl BLOCK/LOT El Sanitary permits <br /> / ,'h• ,r 1 ', - (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> JI v 9 - S &tot Epc ❑ Zoning District <br /> . <br /> This 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 PTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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: 1 ST FLOOR= ❑ EroSIOnCOntrol permit <br /> -- j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 5q 0 <br /> ❑ Review'Location'Survey <br /> ESTIMATED CONSTRUCTION COST: ) STv and available options. <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 ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres 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? Elves ❑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) Elves ENO ❑Don't know <br /> 7. Is this to correct a violation? Elves ❑No <br /> Ai <br /> 1 9 q-, a APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -r -► <br /> 545-112(4/08) <br />