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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 /> wit- ( 11L <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> /101 ;Pi-c.�iy,-�, ,(e,() �,'t 7(/'"'j .5cye2,u4,1 /L. (10/ 7,3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> !4'17:_' 5'7a" , '_ -IP S-75 3 C6t/•,: '(x`"' gfnel% ke JZI'-co• ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> ai ' '1/ V0t. UV/C- 2acet rt/t- a-8- ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 50 C. q- P ksuap � 0-5-C- 4_Rd 4-i--C.Q. 0SC; <br /> (City,State,Zip) (City,state,Zip) ❑ Setbacks <br /> g VrViCi4 ) 14W ? " ((--00[ 75 �' � 4A eJ <br /> PHONE PHONE CI Site Plan approval from <br /> I/Y(7033/e 3 eYi 9'8 / 0 oo/ applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> thel/Df0.,Ctr1(0.-Cidf6V„r{,/! Cdr? - rk Qfi 7L(6r7(0,,igwi/.e((S (0).7 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL �/ 4 -c frontage drawn to scale. <br /> NUMBER O(7'L cal i( � %PO ( T <br /> TOWNSHIP: SECTION: <br /> ❑ Driveway permits <br /> V c:e.�, ,, (/ 1/4: NI its) /4/4: - <br /> (state,county, <br /> ADDRESS: �ff ,1 ( tY town) <br /> d.y I Ct✓✓��'r"C� - TIC ri�,^('.l.(�- ()fr� <br /> (0/ ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ckx &t<1i a,,a-r,,i-.2-L¢o.�ids- e r`c.c,;rt� rav,.n{ (.cet�.C,t-12 <br /> e�.t�-t-e -t -=�- -= Vic-ed Q.krc4�_. ❑ Zoning District <br /> ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> p This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> I«iSitNat{)titl C =ja1BCrnit <br /> BASEMENT: 1ST FLOOR: j TOTAL SQUARE FOOTAGE: j (slopes,disturbance; <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/ac ess) " <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ ♦ `�, ,J C.c ,} CC) 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? ❑Yes G No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes N No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? - aYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? I 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) CA,Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes l (No <br /> G "e 11-/ ( ( 14 , ), ( i) c� <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) <br /> (Continue on Back) ■ ■ -i <br />