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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0 ER NAME <br /> VQ 4 A, D A4 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Stlr`�ee City,,�SSS�t te,Zip) 2 Deed Restriction; CSM <br /> HOME PHONE Id ow l CELL PHONEMIor,013e.,60MAILADDRE9S Variance(# 4005 ) <br /> ,og 57 ~0 , AC.f• 5 G.AI 41000 COWL ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME _ C NTRACTOR NAME <br /> 5011 17 m ,1I Geytz- /46 6)y 40(5 (Ur El Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDR SS of well/septic <br /> II/5 Ali6A4) (4flJ +y4-, �� N5L f. �X <br /> ( sty,State,Zip) (City,State, ip) p/� ['Setbacks <br /> Ccp.32 5j76- ?95� x �Ot 1t� 3 d 1 1 ❑Site Plan approval from <br /> PHONE 1Dlnh ✓t W 5049 op al wf4et't nE ' (V \39R-9767 applicable township. <br /> E--tetAILADDRESS t MAIL DDRESS <br /> , :42 'MA a i� ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION .(http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PAR C LNUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER ©t6 %la - o i-8 Q0Q 5-0 A-a oi,I frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> s`,a,Aa ,(1)~ 14: 3E 1/41/4: ❑ Driveway permits <br /> ADD (state, county,town) <br /> a RE)Ix i S,,, 6,e 'LCle- u) 635a3 ❑Sanitary permits <br /> CSM: LOT ) SUBDIVISION BLOCK/LOT (public, private) <br /> III 1.PROPOSED PROJECT INFORMATION , STAFF REVIEW <br /> PROJECT DESCRIPTION: qq nn <br /> c ei� 5o acs .Ctt1M.566 4 r49e.bo;\,i 11�/11),A\v_ 0. �0 XSO' lPav,�0 4r ❑ Zoning District . <br /> This project is a new building or structure. J tec4ite-.P J 9 U1w:nf ❑ Permitted Use? <br /> []This project is an addition/alteration to an existing building or structure. 6,0,0A , <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ( EWER rEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> RS' ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: 4, (slopes;disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 9/090 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: 80�� and available options, <br /> (Please round to nearest dollar) ♦ '°0 -+ --► -∎ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes 1[7fNo ❑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? [V]Kes ❑No <br /> 4.'Has there been a zoning permit issued for this property in the past 5 years? ❑Yes EINO <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) [ryes ❑No ['Don't know <br /> 7. Is this to correct a violation? c'es ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —0 —0 —0 <br /> 545-112(4/08) <br />