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ZIXING PEF IVITAPPLJCAT 01•1 wwwcountyofdane.com E1�»��a;,ta:����.�a•�_�r•::� <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> I a%Ark. t t 49,t X4 N Gk's NiZoning Status; CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zi ) Deed Restriction; CSM <br /> Z f Q f 14' 40, C ON0 d• ©V eg e N cur 3 s i-r Variance(# ) <br /> HOME PHONE CELL PHONE E-MAI[ADDRESS <br /> 0 , L- r at �•I, 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> $a *.S du.)wt•i S •.. c w AA, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: a cOc 3 CURRENT ZONING: ACREAGE: <br /> 0 PNUIMCBEELR Ai(0 •0 i'a -.1 coa At s x 8o frontage drawn to scale. <br /> TOWNSHIP: . SECTION: <br /> ") CA IAA 0 IA: IAIA: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 2 7- q)1 C- al ev RI, 4veybK cur X31-75. ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> l / V14- l3 a volf K/0%OP ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> QThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER: ❑ Rural Address <br /> DEWER PEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> i c 1 E CI I / ❑ Wetland/Floodplain/ <br /> _ AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> i a. x S 2. 4 TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> Q 11 8 4' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �! and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ 7 Z!O•0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes Do ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Res No Dpon't know <br /> 3. Have you talked with the township about your project and are they in agreement? .'r es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? fr2, es lalo <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) QYes Igo �on't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -. -► -► <br /> w„,19!d 1(151 <br />