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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PRO DE <br /> OWNER tIAME <br /> ig <br /> � d 12bT e h C � C to n h C.1 r S ❑Zoning Stat CUP; <br /> OWNER‘DDRESS (Number,Street,City,State,Zip) Deed riction;CSM <br /> (o(o I-)u.y 2. ., LQronoa w/ 53693 r' Ce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60$-S-3,,-yyyy 7/.Q-.S61-?7 a- pkl,a.>y.l•1, vrverr.to 171. Site lan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and ncludes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> i an including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of w II/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE p Site PI pproval from <br /> app' able township. <br /> E-MAIL ADDRESS E-MAI L ADDRESS <br /> ❑Floor pl to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/) ❑Elevation of property <br /> ❑PARCEL PARCEL SO .- 6201.. 9000CURRENT 7QNING/ ! X ACREAGE:31, ` frontage drawn to scale. <br /> NUMBER �l JJ��11// 1 T <br /> TOWNSHIP: SECT 1,\V ❑ <br /> 'c' t 1M c os-e 1 N '/a : Drivewa ermits <br /> ADDRESS: -16.1"e_ A o (stat ounty,town) <br /> id. 3 a c - ❑Sanita rmits <br /> CSM: LOT SUBDIVISION BLOYK/LOT <br /> (pub' ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> V 'r\ f C a)'A- n oning District <br /> . ❑ his project is a new building or structure. !,J Permitted Use? <br /> This project is an addition/ eration to an existing, building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural :. s <br /> FIEWE EPTIC (ne /existi <br /> HEIGHT IN FEET: NUMBER OF STORI S: (Not including basement) <br /> ❑ Wetland! odplain/ <br /> Shor nd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: j 1ST FLOOR: / ❑ EroSIOnC rol permit <br /> G✓ / + TOTAL SQUARE FOOTAGE: + (s pe ,disturbance, <br /> .,,i% / VVV fi i access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> i(`',�,1 I <br /> Jy(( eview L Ion Survey / �1 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ) �l �0/�-� and I able options. ((( `J <br /> (Please round to nearest dollar) r / 0 v <br /> 1. The property is within 300 feet of a stream or 1000,feet from a pond or lake? [Yes ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Liles o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes Elo <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) Efres ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ['No <br /> r_____— APPLICATION MUST BE SIGNED <br /> S� f (Continue on Back) <br /> 545-112 taroe> <br /> "''-fl <br />