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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME , <br /> 144' °�� ` ) ' `1' Cr ❑Zoning Status;CUP; <br /> OWNER ADDRESS hh(N�umber Street,City,State, Deed Restriction;CSM <br /> 1--)1D I V ` d c A t o Variance(# I oti 79 ) <br /> HOME PHONE CELL PHONE _ E-MAIL ADDRESS <br /> 7 -" III i a -7/a---7, 31 s "• _ _• 1'• : 4, I 121.Site Plan drawn to scale <br /> AGENT INFORMATION ( CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C4 Ito.v_ (5 D 1.4)rt.ear- EiSite Plan including location <br /> AGENT ADDRESS CO RACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) IA Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [Z1 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> NUMBER On 11- 131-crA0-Z /t"a i$, frontage drawn to scale. <br /> TOWNSHIP: SECTIO . <br /> CO RC(5e, --Pov t 3 '/: 14.1/4: Driveway permits <br /> ADDRESS: (state,county,town) <br /> 177t) (V Jar'So RA rc e4S- k.di S33 31 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ®.Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> STAF :REVIEW <br /> r PROOJJECT DESCRIPTION: ,. $ <br /> IJ cJ *Herr e ❑ Zning District k <br /> . gl This project is a new building or structure. U Pemvtted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> �° <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER ZEPTIC (new/existing) <br /> HEIGHT IN FEET: ! NUMBER OF STORIES: (Not including basement) <br /> I 0 D.Wetland/Floodplainl <br /> Shoreland ,(attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 0 ErosionCOntrol permit <br /> BASEMENT 1STFLOO r yy <br /> Li• po i +, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR:'vs filling/acceSS) <br /> 12vO • <br /> •❑ Review Location Survey , <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) "� "� 'i ♦ -o. -► 5-0 and available npfiohs <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ci es ao ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? b es ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? r4 es alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? rA es ao <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) Dees a o ['Don't know <br /> 7. Is this to correct a violation? [Yes alo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) <br /> (Continue on Back) -, -0 -0- <br />