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1.1)'.174 7tif <br /> ZONING PERMIT APPLICATION www.countyofdane.com !===rinl <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> El12-a :.1-c� ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 3�O% l-koll� tic* L� C n to tA)L '5 b233. Deed Restriction;CSM ) <br /> HOME PHONE CELL PHONE lS� Variance(# <br /> E-MAIL ADDRESS <br /> (,1n8-76Lt-87-'1a 2,(P1-(49-)-0 567 bre 0002-0 Yo-h" • cd,y <br /> ['Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> (C)fil u& fv <br /> IX10Vc e W _ ['Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> V,0. 13o / 53H <br /> (City,State,Zip) (City,State,Zip) n Setbacks <br /> 35S1 <br /> PHONE PHONE ❑ Site Plan approval from <br /> Q00$- 2-79_121 I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRES <br /> NIIIA n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURB NT ZONING: ACREAGE: <br /> ❑PARCEL 0'112A- _b378_ I --5 151735v-r4 frontage drawn to scale. <br /> NUMBER J <br /> TOWNSHIP: SECTION: <br /> cC■elci as 1/4: 5€ 1/41/4: N L ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 3e0S WON QACAY-- (-uN C ctc uSZ._ 53523 <br /> CSM: LOT ,4 SUBDIVISION d�S. BLOCK/LOT H Sanitary permits <br /> 5' Z ' f�Yc h� u (public,private) <br /> � 23 :u. .rl RA- dr` =Al, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> De-Ct Sit)PS PGkto ctoof on mormi Side 1�rDper l C22'x(o 5 ❑ Zoning District <br /> giThis 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 FIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> a•S N/A ❑ 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 /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> Pi 3 .ft— (( '�, 4, TOTAL.SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> l filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> •—O:or'(Lt 3 <br /> Li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) -0. -0. -o. -o. "∎ $ 00 , CTO and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 2' o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Lives ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ElYes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#35'10 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) gfres fNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,riNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -i -, -+ <br />