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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME i <br /> 1 I5LA EC ik_"V Wing Status;CUP; <br /> OWNERADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 4:1 5 1 �ar alMt1+ �iUC�� Variance(# ) <br /> HOME PHONE C PHONE E-MAIL 4DDRESS <br /> - 1 N'i' 4-i xi (tog-5'11 - I($1 C_b U LC4yl Q v- , "yV\C;I I•C 0 V1-1 Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [}Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD S Of well/septic <br /> (City,State,Zip) (City,State,Zip) ZyS tbacks <br /> PHONE PHONE ,' ❑Site P approval from <br /> ap icabl ownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F r plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Eleva i•- • property <br /> ❑PARCEL CEO -05 I - 3 y- _r _ /� _ ( 5 56 fro•r.ge •raven to scale. <br /> NUMBER b 300 to IN <br /> TOWNSHIP: SECTI <br /> /ADDRESS: IV1 t c1 d.l R.+U V1 '/a: '/.'/.: ❑Drive mits <br /> ( nty,town) <br /> VI &A/3a mo-1-- \xi c1/4Ni 0 Sarn•.:• •-rmits <br /> CSM: LOT " SUBDIVISION BLOCK/LOT <br /> 1 0 ••• jC, •rivate) <br /> PROPOSED PROJECT INFORMATION <br /> $ AFF - EW <br /> PROJECT DESCRIPTION: <br /> b rt.0 ing District <br /> . El This project is a new building or structure. P ed Use? <br /> Is project is an addition/alteration to an existing building or structure. <br /> SANI ARY SERVICE: PERMIT NUMBER: ❑ Rural Add t <br /> EWER EPTIC (new tillik <br /> HEIGHT IN FEET NUMBER 0 OR S: ( including basement) <br /> I O <br /> 11 ; a. _ ..la•••plaid/ <br /> a.: ..mot r ent�, , <br /> AREA TO NEAREST SQUARE FOOT: �o �I/a�1 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) • I! <br /> E E . t . permit <br /> BASEMENT 1ST FLOOR: 3 <br /> TOTAL SQUARE FOOTAGE: + - •r* •.rice, <br /> ing/. .t ) <br /> 2ND FLOOR: 3RD FLOOR: ` <br /> . (� Review Location Survey <br /> (Please round to nea esCdoll)COST: $ 3 ic and ava options. <br /> /110 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes OW ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes �o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®1'es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ❑No <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 EiNo ❑Don't know <br /> 7. Is this to correct a violation? :Iles 2N0 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -i -4, <br />