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Z� � <br /> ZONING PERMIT APPLICATION www.countyofdane.com , SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> CIAn.s4-,va ;I1 / /4;CieIle Spey) ❑Zoning Status;CUP; <br /> Ow R?ADD RRESS umber,Street,City,State,Zip) Deed Restriction;CSM 1l£✓lJ1`t re i�n Icn (Pro)r-e WI . Ss--- <br /> 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 /> K14,1 093 I. t)ojd.g- -RevNrjGl'i nij ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ,..c.249 (ommecc.;a / ,4ve_ <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> vt-Pi.&i r,.e (47" s7,5-91) <br /> PHONE PHONE ❑Site Plan approval from <br /> 6,020 8,37- 6,3i 2 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS a <br /> adasi. z i.,nater•uaq e,�cNa:.4fs ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) O d 3 i <br /> - <br /> Floor <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation <br /> of property <br /> ❑PARCEL J of /1 y9� frontage drawn to scale. <br /> NUMBER ©��/et ID 021 22-1 (� t g <br /> TOWNSHIP: SECTION: <br /> �V I—ke-- /4: ,%,A. ❑Driveway permits <br /> ADi RESS: (state,county,town) <br /> C��l Det/o4_4itrL ,L i-tn Pia i r;(, WI `a3�7 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> I. FOx MDOr J- i Its (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> DCreesil orr--k Add i4 ❑ 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 EPTIC (new/existing) <br /> HEIGHT IN FEET: / I NUMBER OF STORIES: (Not including basement) <br /> to 1 3 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 /> +, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> kg ❑ Review Location Survey <br /> ( <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ O t�d�' _ 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? DYes ■1No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes ,TidNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 07es 13 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes [ o <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) DYes /A o ❑Don't know <br /> 7. Is this to correct a violation? DYes al o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) ) ♦ <br />