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-' I ,t-AC- 1 Ct 0 t ----, --;P 1 !ALVA CP3 I --) 1 Cc C•7 r ,.. ,, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /� <br /> -- V fS Cit/g/ct M D Zoning Status; CUP: <br /> HOME �E9���r sue city. Zip) f� „ W Deed Restriction; CSM <br /> u (4--e` H� ��� S 3 S 2 Variance(#__________) <br /> PHONE CELL PHONE E-MAIL ADORE : 1_ // <br /> 4f3 - 6 g bqZ•- '8 /2 L C w•/''t !r - pi el-- O Site Plan dr n scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes ' nsions <br /> AGENT NAME CONTRACTOR NAME <br /> _ O Site Plan n iding location <br /> AGENT ADDRESS of well/se O-�D� S <br /> - O Sete <br /> (City,State,z. ) (City,State. .p) <br /> 4 �/ ❑ Site PI=n royal from <br /> _ i4 PHONE PHONE J h <br /> applic•�• - o nship. <br /> E-MAIL ADDRESS E-MAIL ADORES Floor Ian t Cale <br /> f-1 P <br /> PROPERTY/LOCATION INFORMATION (http://accessdanw.eo.dans.wLusl) n Elevation of pr erty <br /> PARENT PARCEL NUMBER op CURRENT ZON1 G' ACREAGE <br /> ❑PARCEL D6o/6 '' "3�-2.. A 2 (E x) +1 - Z$ 6 frontag n to scale. <br /> NUMBER _ <br /> TOWNSHIP SECTION: n Drive a \ rm11S <br /> V e✓i A o�t��- 'A: '/,'/,: (sta n .town) • <br /> ADDRESS /� / / ?S7Z ❑ <br /> 9 9l6 ✓22v► 14, if Pi mil• l f JYe4 h -3}L SaniA e its <br /> a CSM q LOT SUBDIVISION BLOCK/LOT (pU C, I <br /> • PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROc RIPTIfI 5� 0140o/el Q n'' t,S /T,- <br /> 54-0rl Zonini trict <br /> This project is a new building or structure. Li Permid/Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: NUMBER n 1 / ❑ Rural Addr S <br /> [EWER 1)EPTIC /APERMIT f_` (/4 (new/e Stiih <br /> HEIGHT IN FEET. j I �1{ CUMBER OF STORIES (Not induding basement) u Wetland/Floodplain/ <br /> `/ 1. �/ Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r, ErosionControl permit <br /> BASEMENT AI 1ST FLOOFj, r L` 6 5 j TOTAL SQUARE FOOTAGE: j (slopes, disturbance, <br /> N `!� 'C filling/access) <br /> 2ND FLOOR. ` , /4 3R0 FLOORN /A. 3, , / 65- <br /> (� ""C _l Review Location Survey <br /> ESTIMATED CONSTRUCTION COST. --► ♦ ♦ --o. -•► $ 3 v/0 O p p and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Oyes ria o ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? [-Yes egi 'o ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes r4No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dyes io <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) Res Oo ODon't know <br /> 7. Is this to correct a violation? es ONO <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -+ -i <br /> 54S-t12(om) <br />