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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> L e. P G y 4 M A r r,a- / / Li e. v e_ r ❑Zoning Status; CUP; <br /> OWNERADDRE9'S (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> (o D n I C 'l v A rD 4 (3,/od 1`' ,cv ii}-7--573 S- -4 / Variance(# ) <br /> HOME PHONE C L PHONE E-MAIL AD ESS <br /> L 9 D: -Z //(,J, . - - _ - . e;... ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME /� <br /> c I me,r l.,e"7 n5 7rc_ct,vni ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> / . / td, r o e. ST- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> _ <br /> PHONE PHONE / ❑ Site Plan approval from <br /> (tag - 5-2 7— 7o q/ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL UMBER: CURRENT ZO N " r ACREAGE: <br /> ❑PARCEL Doi' �2 06 A frontage drawn to scale. <br /> NUMBER �^'� L <br /> TOWNSHIP: SECTION: <br /> 0 rG -I" 1/4: IA%: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> °?" C1--i+ 4. El Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION ',!"STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> P)e ,- 1.,4 c e A ri U t x�r inr� el <br /> c K ❑ Zoning District ; <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 r)EPTIC - (new/exis"ting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> U Wetland/Floodplain/, <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1STFLPOR: ❑ ErosionCQntrolpermit <br /> 2 '7 7 4,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: / A filling/access) <br /> CQ 7 7 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: , a° and available options. <br /> (Please round to nearest dollar) ♦ ♦ "0. ♦ —0 --0, 9 hi 7 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des ao ❑Don't know <br /> [-Iles 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 LNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ElNo <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) Eves No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes EiNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/081 <br />