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ZONING PERMIT APPLICATION www.countyofdane.com <br /> 010514-NAME CUSTOMER TO PROVID �! <br /> • }v�l,'"1 / ,I'bS S Zoning Status;CUP; �° <br /> OWNER ADDRESS (Number,S�,City, tate,Zip) <br /> Deed Restriction; CS <br /> r-4-63;/ L) vgA Cl- Variance(# ) <br /> HOME PHONE CELL PH NE E-MAIL ADDRESS <br /> 93 / C,DZ'57.3,*y/ '' - 'ju H ,c_. ),,,, Site Plan drawn to scale <br /> Raroll riAmtNurror4 and includes dimensions <br /> CONTRACTOR N M <br /> 001/.'L.J/43 kle Site Plan including location <br /> af <br /> t. <br /> AGENT ADDRESS CONTRACTO ADDR SS <br /> of well/septic <br /> it <br /> (City,State,Zip) (City,State,Zip) y ASetbacks 30/5V/0 3 <br /> PHONE PHONE n ite Plan approval from 4 <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS r <br /> Floor plans to scale <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: Elevation of property <br /> ❑ NUMBER d I 09/�9II- Ill- �-3_ 164. `I frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 6 410/ II '/4: 0 L 1/41/4: it,t (state,county o <br /> ADDRESS: <br /> T l 0 r Cf 5� r YL(i U I <br /> i3V.° `Sanitary permits <br /> CSM: LOT SUBDIVISION ' BLOCK/LOT <br /> (public,private) <br /> STAFF REVI <br /> PROJECT DESCRIPTION: / rr / r. <br /> bezi A i"1 o✓1 A x a`/ Zoning District" ''"'~'` <br /> ❑This 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: PERMIT NUMBER: tit Rural ' " <br /> ❑SEWER ❑SEPTIC (new -xistin. <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ri .! s•dplainl <br /> AREA TO NEAREST SQUARE FOOT: orelan="(attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ) <br /> BASEMENT 1ST FLOOR: <br /> EroSionControl" 1,--11 permit . <br /> ,= TOTAL SQUARE FOOTAGE: I (slopes,disturbance; /9/ (, <br /> f(llin <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED C WO ON COST: ♦ ♦ ♦ ♦ ♦ Q �� • available <br /> (Please ro i est dollar) $ t5OO. <br /> 1. The property is wRMitr'300 feet off�s� stream or 1000 feet from a pond or lake? ❑Yes ❑No C3 Don't know <br /> 2. Is there a \land or flood�liQ��l`f"'or near the property? ❑Yes ❑No Li Don't know <br /> 3. Have you talked w tttM -township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there btr1' bning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is thict associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Li Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />