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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> • <br /> PROPERTY OWNER INFORMATION <br /> CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> TO W N 0 ? (k' 1 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 13 1.)(0 cli+-Ti tit&Hj / Y '1g, IMT. time: 3 ) w_i_- s 35 la._ Variance(# 021 O'- ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> 1' - ySS3' N : LSite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME o -r _'at-iu Wtkt4 CONTRA TOR NAME <br /> \oJcr hO N, riZl.M)Malt 146VISOP-f Lit. fro Rt.--, DTt igia) ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic p ti. <br /> t 1 t✓, Loc, -wnc© 14w, *2_01z) ,—� <br /> (City,State,Zip) (City,State.Zip) 1.1�Setbacks <br /> PHONE PHONE llef Site Plan approval from <br /> '3l H- et b3-1-t 0o applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> QrFloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: i, (��p t.CURREN ZONING: ACREAGE: U'Elevation of property <br /> 53 PARCEL <br /> NUMBER 0+4/650.-O SLi All i-Y 4-2._(2-) _I frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -Pe ILR 5 '/\: S c //: S t 1:1 Driveway permits f fk <br /> ADDRESS: 3 '?82, Pte.,“? Gr4lr 5 (state,county,town) / <br /> 134RSA0 S'114 H1ErHttlivY '1`6 1 -l• ttJ ia,ytiZ 53S1a- ❑ Sanitary permits wlA <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (o t q /, -R-R.,4 T04/4 u�k (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 0 e Cl-u Lpr . -Rt VJ .-V fZ11,0l W 4LE Lt;3S ❑ Zoning District <br /> . Hillis project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: iv/ PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> �(� 1-�L (t%s,A4L,L&µ��W \ ❑ 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: 1 ST FLOOR: ❑ ErosionControl permit <br /> _, , TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ u and available options. <br /> (Please round to nearest dollar) 1V 1 v00, 0I, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1rNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑1 Jo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? L es ❑No - Tt '► `A�0 lifexia <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Clio 14-1-TA TA-5-v-) <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# al O 4- ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) i Yes Li No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Itfio <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -* —► <br /> 545-112(4/08) <br />