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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 /> ❑Zoning Status; CUP; <br /> OWNER DDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Thy. . 0 V Itka ON/. Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT;INFORMATION CONTRACTOR.INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C�) 1+ f M 06t It f-j.. .e ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7� Ckcv� (f S c--►(1 'I 5-1 C_1,,<<.v 1-e S C (r) <br /> (City,State,Zip) (City,Stat Zip) ❑Setbacks <br /> PVIONE , PHONE ❑Site Plan approval from <br /> V�t N ) 51 3_ , 159 _ applicable township. <br /> E- AIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION:INFORMATION-..(http://accessdane.co.Aane.wi.usl);: ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONIN : ACREAGE: <br /> ❑PARCEL / p 9o0 ? �, 7 50 frontage drawn to scale. <br /> NUMBER 66 0 `Z c Z — 1 > <br /> TOWNSHIP: SECTION: ❑ Driveway permits <br /> •GG( ( S® Y\ .Z ,A: 1/41/4: (state,county, town) <br /> ADDRESS: —} <br /> l �0 r M CL U\ f) \ . ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION 'STAFF REVIEW <br /> PROJECT DESCRIPITION: <br /> /gym , (.� o iv) -L ❑ Zoning Distract <br /> }k <br /> . his project is a new building or structure. •❑ Permitted.Use? °' <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVIC PERMIT NUMBER: ❑ Rural Address <br /> WER EPTIC (1lewfexisting) <br /> HEIGHT IN FEET ( NUMBER OF STORIES: (Not including basement) <br /> ❑ 1Netland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> ❑ Et9SIOnCQntrol permit <br /> BASEMENT 1 ST FLOOR:(&' 1 1 TOTAL SQUARE FOOTAGE ,, slopes disturbance, £fi <br /> fhIingtaccess)r' t -' <br /> 2ND FLOOR: 3RD FLOOR: / / 4` t4 0, ,,,a.' a <br /> ( f b I ❑ Revtevv Location Survey ' <br /> ESTIMATED CONSTRUCTION COST: and mailable options <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ 1 o 0 C <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? - ❑Yes No • ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres :Etter .. <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 'LIEtttur . <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 4 t p ['Don't know <br /> 7. Is this to correct a violation? [Yes Na. <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 -I -► <br /> 54$-112(4108) <br />