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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 /> 4A%("`� ST.41)---(r-k.:7. 11,1\-9 `S`'"--, / (--c— lEloning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3► 5 1,e,c_l; Ptl„A-cu'" , 51Z-- //y /-040 )s d,../ 1' -C 5-3•,-+05— <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 3 - /5-1)-3' -4-"+„1 - a O / ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME NTRACTOR NAME <br /> 6(+0&i etom-.-o R,.- t.,- s.iSr. z--c. Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 30,E a t t- S-" TY2/4-r L <br /> (City,State,Zip) (City,State,Zip) EiSetbacks <br /> PHONE PHONE Site Plan approval from <br /> (1m(/' - --Gj Cr.- .2.1�-y applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> (gg U. G C „S_ ti t=- Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) evation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ‘ ACREAGE: p p rtY <br /> ❑PARCEL u r� frontage drawn to scale. <br /> NUMBER 01-0 ' - �53 'It'd V S`-s �- oz. 0 • �5i� <br /> TOWNSHIP: SECTION <br /> - <br /> FY1 t 0 0 I,I -rb vg S '/4: '/1/4: Driveway permits <br /> ADDRESS: (state,county,town) <br /> fort 3 SE 113 ot.,p aoprb <br /> Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPT ON: �,/ <br /> 11 a t) IP 5Toft."--(,c /3t-.-6(,-- (})O ri n"-...) lV Zoning District <br /> ❑This project is a new building or structure. ,� <br /> L`y'Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: LI Rural '.-_ -ss <br /> tgl EWER r)EPTIC (ne 4160!) <br /> HEIGHT IN FEET: �. NUMBER OF STORIES: (Not(Not induding basement) <br /> tland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR:. /� roSIOnCOntrol permit <br /> t/' 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 149 on filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: i -► -► Q� � and available options. C <br /> (Please round to nearest dollar) $ /Z0 C )0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes 7410 ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ro: o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? igi'es • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Wes Elo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#0 l 0 38j (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ■ es ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes giNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(4/08) <br />