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, • <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / <br /> 0 a to i Pestle 6 raC KNl a 4 i <br /> Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> (0 f/ C-5/0 L c a e 5( f) 1 t're`e .573,7 go Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60e-al.)=NW ,=4 Site Plan drawn to scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includes dimension• _0 <br /> AGENT NAME ,,,s-' CONTRACTOR NAME /� <br /> -"ru 6 1',0,1 .1,." °" f'" row c W e it root 5 1-`_ S+r gi Site Plan including locatio <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> e i(8 tit Leal A 6 <br /> (City,State,Zip) (City,S te,Zip) IN Setbacks 307/0/0 <br /> PHONE PHONE Site Plan approval from ,/ <br /> cp c e as -173 0 applicable township. /v ' <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wLus/) I 0 <br /> PARENT PARCEL NUMBER: CURREN ZONING: - ACREAGE: Elevation of property <br /> 0 PN 0t2 0911-fgq-�1512`o — I D oV e- /D' frontage drawn to scale. <br /> TOWNSHIP: SECTIbbb • , / , ( <br /> S c 6+0 ys: SE '/4'/4: S W Driveway permits <br /> ADDRESS: (state,county,tOa <br /> ePq/I Os Lame 5-0 r\ 0ra,irlE , J". 5.3.i 'O <br /> KSanitary(puli pe_• its <br /> CSM: LOT SUBDIVISION I BLOCK/LOT <br /> 2- Lekw• ti S (public, , ) <br /> PROPOSED-PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: `� / I A <br /> n C{r( vt� U1 t Nt w D-C�l to "X oning District /` `/ <br /> . [1This project is a new building or structure. ar Permitted Use? L- k""9 <br /> This project is an addition/alteration to an existing building or structure. Ott <br /> SANITARY SERVICE: PERMIT NUMBER: ,Rural Ad• <br /> EWER %EPTIC (new/-xlstin• <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) A <br /> Mill W- -g• oodplain/ <br /> orelan• (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> g:ErosionControlpermit <br /> BASEMENT 1ST FLOOR: /' q <br /> /� 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, i 47 <br /> lJ I filling/access) A" <br /> 2ND FLOOR: 3RD FLOOR' C �jy <br /> l/O UUXX Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ ♦ ♦ ♦ $ /�/' and available options. <br /> (Please round to nearest dollar) $ pod, D <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 ao nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? :Yes 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 ISINo :Don't know <br /> 7. Is this to correct a violation? - f es [ to <br /> t Yr 6 ,0 <br /> A' 'LICATION MUST BE SIGNED <br /> ontinue on Back) —► —► —► <br /> 545-112(4/08) <br />