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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME n <br /> L-.iSr1 R Ropvsock - Pe-v.1-61, ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number, reet,City,State,Zip) Deed Restriction; CSM <br /> 2-iiq aw B 6 1sikad,5,,, (iv 1 535-1 i <br /> Variance(# ) <br /> HOME PHONE CEL PHONE E-MAIL ADDRESS <br /> (•O$..511' ci I 4-140? 64-6" ' ` `�0 i"" ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> '; t1 SJAQ et.,,,q , ll ()Jc,,wL 1-t-c- ❑Site Plan including location <br /> AGENT ADDRESS ( � CONTRACTOR ADDRESS of well/septic <br /> 5z2 . Cci{c.5e C rave l4i 5 zz2 Ca` =cle- C,,o ve Rei <br /> (City,State.Zip) (City,State.Zip) ., El <br /> Mad,So-v. ks( 5311 L. Nat1 t sov. i s t 116 <br /> PHONE PHONE ❑Site Plan approval from <br /> 670O._41.9 _:34 f1 ,o8 - 40 -34-11 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> h _ ke.a, • o , vie-'t— bi I Igloiut40.4:_g i (L,Govv( ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.daAC <br /> REne.wi.AGE:us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING. <br /> El NUMBER ®t&i/i l -o1 i_8860-Z 61 / Z1 , Z2 j frontage drawn to scale. <br /> TOWNSHIP: !!! SECTION: <br /> w --ca cic, 6,ro Jd_ 3 1/2: <br /> 1/21/2. ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> Zglq C4.- 4w Fs5 <br /> CSM: LOT SUBDIVISION I BLOCK/LOT ❑Sanitary permits <br /> I (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF-REVIEW <br /> PROJECT DESCRIPTION: ji� L / <br /> A rU G� t QG Fc-S �r' CIGG2`fj �,.-- .k i,re•c:✓ 4 (40 0 sg._.❑ Zoning District <br /> ❑This 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 NUMBER: ❑ Rural Address <br /> EWER j EPTIC *lS-/-, , (ttew/existing} <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Ph A4 I. 4-1103, (r f rek v ,rcl.3' t•1/pp ❑ We nd/Flt tplatnl <br /> �1' Shoretand (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionContiol permit <br /> BASEMENT: 1ST FLOOR: / [ TOTAL SQUARE FOOTAGE: j (slopees,disturbance, <br /> nce,sminw 2ND FLOOR: 3RD FLOOR: P?'3 <br /> ❑ Revievicatition Survey <br /> ESTIMATED CONSTRUCTION COST: and av le p tions. <br /> (Please round to nearest dollar) ♦ ♦ _p, ♦ _+ Zs GYM �JOO v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Lives [ lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves ❑No ®Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes K 'Jo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves 'lo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# .;8 7 7 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Elves ❑No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes "lO <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />