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ZONING PERMIT APPLICATION Www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE 2 <br /> OWNER NAME 5 A <br /> cv\ rK 6 5 h e.1\ 0 k J � <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Status; CUP; 7 <br /> �.y 8 6 N Q`\ �o c Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE 1 CELL PHONE E-MAIL AODRESS <br /> 4 558 ,-- 0 9 4 1Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA TOR NAME a <br /> lc CS\MN cL) )'‘\`, Le.s5 ( Sit- - ••c u. g location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of ell/septic <br /> 4"01 u '1 1S\(\nke, °""' a <br /> (City,State,Zip) (City,State,Zip) 'Of Setbacks X3/3 /U ( <br /> co tt-1 1, b 101...)e-, \f3'0 S3-5V <br /> PHONE PHONE Site Plan approval from. /' <br /> — <br /> C b a(� _ 'I Lk o%. applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> o Q, + �cr n fir ,wi .*I , t✓b M IZIFloor plans to scale <br /> /4/PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.usn PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: Elevation of property <br /> 0 PARCEL r �1 n / frontage drawn to scale <br /> NUMBER 0 ,8 /O / I'—� �15'.a !"■'� ), ( \ �" <br /> TOWNSHIP: SECTION: <br /> LAO\ e. C CaoSt " -ill 1/4: wA; Driveway permits <br /> ADDRESS: (state, county, <br /> --),14`14 $D 'n`6 SZ.64 Sanitary pe•••' <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> a 1 (P , (public, �i <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ��,A,\*\ yJ9z ) ),✓ )Do. )c \\ vt4 Zoning District Z,6)) <br /> 1 <br /> This project is a new building or structure. <br /> p ) g Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Add d—ss <br /> EWER ØEPTIC (new/HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)2 / g W floodplain/ <br /> / AREA TO NEAREST SQUARE FOOT: orelan (attachment) 1 4— <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) .. <br /> BASEMENT: 1ST FLOOR: ErosionControl permit <br /> /2 O 0 4, TOTAL SQUARE FOOTAGE: j, (slopes,disturbance, f o f <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1 g, O 4-0 7, <br /> XReview Location Survey / <br /> ESTIMATED CONSTRUCTION COST: -• -• -• -4- and available options. <br /> (Please round to nearest dollar) ` i )P eb, by <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes ®No DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? []Yes N o DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes 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) 1 Dyes Ilo DDon't know <br /> 7. Is this to correct a violation? DYes J '4o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />