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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAAM�ME11 I' <br /> V � 1 v 1,k ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street City, ate,Zip) lj. 4 �L4„3 4i R/ <br /> (/o�,,, `I� �' ` Deed Restriction; CSM <br /> HOME P ONE CELL P�( E-MAIL ADDRESS Variance(# ) <br /> a1 3 —175 • .---- ❑ Site Plan drawn to scale <br /> AGENT INFORMATION. ,. CONTRACTOR_INFORMATION ., , and includes dimensions <br /> AGENT NAME Cf NTRAC, OR NAME <br /> C. <br /> V 1(�j 'cYa_1!1 L L ❑Site Plan including location <br /> AGENT ADDRESS CONTRAC1[OR ADDRESS of well/septic <br /> —75`1 C.C KS U� <br /> (City,State,Zip) (City,State,:Zip) ❑Setbacks <br /> S'(- A y ht,-1- s3 Sec <br /> ❑Site Plan approval from <br /> PHONE C(c5)513 //..517 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> _---1--- ❑ Floor plans to scale <br /> PROPERTY/LOCATION.INFORMATION,:(http a/acciessdane.co.dane .wi.us/): ❑ Elevation of property <br /> PARENT PARCEL UMBER: C RENT NING: ACREAGE: <br /> ❑NUMBER oc O 0. 70003 c0.38' frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> I ■ t,■V\ '/a: '/4'/4: ❑ Driveway permits <br /> AD ESS: (state,county,town) <br /> q 7 A-0,-/ r°- <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVI';EW 4 <br /> PROJECT DESCRIPTION: <br /> j`e p v k .I. A4M ca yC/2- le,-/G h/X S D`e ❑ zoning Dlstnct <br /> . '.This project is a new building or structure. ❑ Permitted,Uses <br /> ❑This project is an addition/alteration to an existing building or structure. , ': <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural AEidee <br /> . rFpEWER r)EPTIC (newLexisting) <br /> HEIGHT T: NUMBER OF STORIES: (Not including basement) <br /> 4) ❑ Wetland/Floodplain/ <br /> 75 AREA TO NEAREST SQUARE FOOT: ShOTelBnd (BttaClment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Eo ►onContro( ermit <br /> BASEMENT: . • 1ST FLOOR: <br /> . I33., 4, TOTAL SQUARE FOOTAGE: _ sopes djsrane, <br /> , tillngfaCC @SI z <br /> ti <br /> 2ND FLOOR: 3RD FLOOR: / 33 � i:z a <br /> ❑ Review Location-Survey <br /> ESTIMATED CONSTRUCTION COST: $ �V U O and avaiiabte options <br /> (Please round to nearest dollar) "♦ _—■ ♦ --► --1► ♦ 0 , <br /> I <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? ❑Yes ❑No ❑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? ['Yes ENO . <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> L 0- 6 APPLICATION MUST BE SIGNED <br /> , (Continue on Back) —► —► —► <br /> 5.45-112 OM) <br />