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' ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA /n� `n 1 <br /> coil /7 n ✓� 1 �0 eS ( `� ❑ Zoning Status;CUP; <br /> OVER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (oO& 9la-6j9 I ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> ANT NAME CONTRA TOR NAME <br /> t;/�I �toc� ����5 Cz onStrucfionFttrvueil" 1-n.",❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /CS?S? /3v r ve rca <br /> /557 &&n✓e (c <br /> (City,State,Zip) (City,State,Zip) n CI Setbacks <br /> Deep s � ) 1-)7- 6-35--- / Dee( �,\D 63 6,3/ <br /> PHONE ONE ❑ Site Plan approval from <br /> 60e 35r-053 g l 6 36-"t-0C31 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> crcorj t hierr•• Go r)--) CI <br /> plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usi) <br /> El Elevation of property <br /> Y PARENT PARCEL NUMBER: CURREN A OH G: ) ACREAGE: <br /> Li NUMBER 0(o I c -1 3-k39D-d <br /> 3,6 frontage drawn to scale. <br /> TOWNSHIP: SECT RI: <br /> C A6151-1CInq 1 1/4; 5IT) 141A: 14 ".... ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: _ - / <br /> Z L!S.5- C , > LA) ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ia yo�o 1 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 51 (j).e c - A Vo m e ❑ Zoning District <br /> ID This project is a new duilding 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 /> ❑SEWER 0 SEPTIC Sa035-32 (new/existing) ;,. , <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2 0 ' I ❑ Wetland/Flood*n/ <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: 44 r6S e <br /> C3 EXI,,9,24-to 2140� ///v TOTAL SQUARE FOOTAGE: (slopes,=CIiS 11'7 " <br /> of V !'1 fit i�C1 5S <br /> 2ND FLOOR: 3RD FLOOR: ��:f. � fi.�SsL, �. <br /> Review 'OC Stlrve <br /> a�f?n <br /> ESTIMATED CONSTRUCTION COST: ♦ --► ♦ --► -0. $ c c 5 U U0 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 ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 131No 0 Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? =I Yes ❑No <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 ❑No Li Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> el e2" <br /> 5? APPLICATION MUST BE SIGNED <br /> 545-112(4/09) <br /> t <br /> �/` O v (Continue on Back) -, -► -► <br />