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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/ZyA"1 57E6 a Zoning Status; CUP; - / <br /> OWNER ADDRESS (Number,Street,City,State,Zip) y� _ <br /> /37 S (d.N N cm/42A LN oge yvAi / vi 3 S 3 57 s Deed Restriction; CSM / �d <br /> HOME PHONE CELL PHONE { Variance(# ) <br /> E-MA LADDRESS <br /> — 66'6- 65y-77 3(o TKS, ST�tI Z-{ e cm/y1 R It , LC)Al\ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME // <br /> LAKE CL.NTa-'( CANSi2n.Cf pw Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> it)/ Nvrt.►zoN Dry #/03 <br /> (City,State,Zip) (City,State,Zip) Setbacks ' O/"o(o/J <br /> V><RoiA , lAir .5-3S-g3 <br /> PHONE PHONE In Site Plan approval from ,_/`� <br /> (p645— 2 2 .S — /3%q applicable township. /�/ <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ,e3z6 ,j4kE6s,.,Tny 4 ii,,, ,c,), in Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBE . CURRENT ONING: ACREAGE: ,1Elevation of property <br /> ElPARCEL ,c0 7-Q2/^30W F X^/ o ?s-- frontage drawn to scale. <br /> NUMBER / 7 <br /> TOWNSHIP: SEC/TJ/Q --- N 21 <br /> -Driveway of 01Lt U,0,3 (/ '/a: +/a1/: ^L1-Driveway permit <br /> ADDRESS: (state,county OW <br /> I 33 S C_01./KJ EM Ala Sanitary per its <br /> CSM: LOT SAM VIi TON }�■(�S BLOCK/LOT z-- ublic,g <br /> (P <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / r <br /> � 'ti <br /> bEc-� ON TI-IC Bttc Sic£ of j{p,-use" /2 )C ZO L1 %Zoning District <br /> r/ <br /> ❑This project is a new building or structure. /4/`X I Z' F X S< /08 v S <br /> Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structures /5 A G=-% i Sc / <br /> SANITARY SERVICE: PERMIT NUMBER: ,WSJ Rura <br /> EWER [)EPTIC (ne existin ' <br /> HEIGHT IN FEET: U NUMBER OF STORIES: (Nqt including basement) <br /> / Wetland/F000dplain/ <br /> A <br /> Shoreland (attachment) /VA <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: Erosion Control permit_ <br /> v5-6 4, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, 73 <br /> 2ND FLOOR: 3RD FLOOR: filling/access) 1 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q /`� 1) and available options. <br /> (Please round to nearest dollar) ♦ ♦ _ '� ♦ -4 $ 0 6 1 (% <br /> r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes X No Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes QNo ®Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes lalo <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 QNo Don't know <br /> 7. Is this to correct a violation? QYes jlo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 la,osl (Continue on Back) --. <br /> S � 363 <br />