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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 /> Br i d r tehy BSI!v i n) ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Numbef,Str et,City,State,Zip) Deed Restriction; CSM <br /> � + H ONE C+ ( Rd CELL L PHONE C'+7 E-MAIL ADDRESS <br /> S1 3 Variance(# ) <br /> HOME P <br /> Iraq" 31,3- O9 ❑ Site Plan drawn to scale <br /> AGENT•INFORMATION CONTRACTOR_INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> qr N- Pools r SP4- ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> PO Ow i c <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> fv-,f j)' wL. 53919 <br /> PHONE PHONE ❑Site Plan approval from <br /> (r d Y' gtc3 —3o 9q applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> r h,..d 4.)i c w; ppD)s a c ci"'"----- ❑ Floor plans to scale <br /> PROPERTY/LOCATION,INFORMATION,:.:'(httpa/accessdane.co:dane.wi.us/y. ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: <br /> ❑NUMPARCEL BER C c 20 S —1-1 ni 3,4 NIl ) (Ex) 3 q) qo a frontage drawn to scale. <br /> 'F i� � <br /> TOWNSHIP: SECTION: <br /> RC amber /a: % : ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 9 l 0 G�7 �� <br /> j 'l' Sys k c 717 144--, 113 re3 <br /> CSM: SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF' REVIEW <br /> PROJECT DESCRIPTION: / <br /> ,•15/*c✓ 514441-,4 ,,v?r1] /00( ) S / eY y 0 0 !Zoning District - <br /> . <br /> This project is a new building or structure. ' 40 Pe.rmitted.;Use? <br /> ❑This project is an addition/alteration to an existing building or structure. v <br /> SANITARY SERVICE: PERMIT NUMBER: '.0 Rural Address <br /> [)EWER neWIeXlS ing) <br /> HEIGHT IN FEET: PEPTIC NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ ErosionCt ..- - permit -` <br /> BASEMENT: • 1ST FLOOR: i x <br /> wlj (—, j, TOTAL SQUARE FOOTAGE ,jslapes disturbance, , <br /> :� rS-i��rs�'s�s '�te, � it y+�; <br /> . fllmglaccess) <br /> 2ND FLOOR: 3RD FLOOR: _ <br /> 7 ): 0. <br /> 0 Review Location,Survey. <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ' rid and airat able options <br /> (Please round to nearest dollar) 1 i 31 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? vYes ❑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? Eyes 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) Eyes ENo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Rico <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —t► —► <br /> 545-112(4/09) <br />