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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 /> Jeci e i V( ❑Zoning Status; CUP; <br /> OWNER ADDRE (Number,Street,City,stag iP)(' C Deed Restriction;CSM <br /> 2001 Washih�-tan Via .fin _. 53Syq Variance(# ) <br /> HOME PHONE CELL•HONE E-MAIL Ali DRESS <br /> 6o 516-72RS Ved -1 ® S' e•Jabal• het ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT�N CO TRA TOR NAME <br /> Z 2 Veiii 9 in i • uat.l h ❑Site Plan including location <br /> AGENT ADDRESS -ton P.D. ig9 Nackl -g <br /> I <br /> (C' State,Zip) (91y,Sta i ,Zip) ❑Setbacks <br /> 0ughfbn W+ 53 5g9 .r I W► 53 9 PHON �/ � C PHOG 09O-5 Site Plan approval from <br /> o ) 544" 2 /�7 6 78 applicable township. <br /> E-M LA'DRESS E-MAILAIDRESS <br /> 4 Y► 4 , d v�I • n e4' ❑Floor plans to scale <br /> PROPERT.'/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El of property <br /> PARENT PARCEL NUMBEIT.❑NUMBER <br /> ER 06112612%'3d O C EN i ZONING: ACREAGE: frontage drawn to scale. <br /> TO SHIP: S1Princjc SE O I 6 <br /> /eaSan+ 14: SE WA: NC ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: �j 2 dU-1- aSh►n�-fan /22d ❑Sanitary permits <br /> CSM� `�� LOT1 SUBDIVISION BLOCK/LOT <br /> 6 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT ESCRIPTION: <br /> rage -+ porc1 added 6h 4a £X)S-r)45 f) /1oML. ❑ Zoning District <br /> EFT 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 Is UMBER: J{ CI Rural Address <br /> �J U r <br /> EWER PTIC -111-1,511 -03 9 (new/existing) <br /> HEIGHT IN FEET: , NUMBER R OF STORIES: (Not induding basement) <br /> i s ❑ IMetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached gauges and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: C ii ❑ ErOSIOnControl permit <br /> /n 5/6 so Fr gtl [t j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 8 I <br /> fining/access) <br /> q4#0 Fr ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) $,i W/�j O. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EI'Jo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes flo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 12Yes 0No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Oslo <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 alo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) /1 / „ (Continue on Back) -► -∎ -r <br /> 6r,)- <br />