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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Q.uid I-I 4 /1/4nc,// t' KeVI •9- Zoning Status; CUP; 120.-( <br /> O NER ADDRESS (Number,Street,City,State,Zip) <br /> `Deed Restriction; CS <br /> q‘,2yy cpi-' rig ()G LI'e '-/ 1?1, /(1z--0141121e 60 53 0 _ Variance(# l <br /> HOME PHONE ELL PHONE E-MAILADDRESS <br /> / <br /> (001 74 S /to Site Plan drawn to sca e <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic 3A00//5/50 <br /> (City,State,Zip) (City,State,Zip) ( Setbacks 6 <br /> PHONE PHONE a Site Plan approval from Ai <br /> applicable township. i/v <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 8(Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> %Elevation of property <br /> PARENT • CURRENT ACRE GE: p p y <br /> 0 PARCEL i ff'— I '� i 3 Z g frontage drawn to scale. <br /> NUMBER / <br /> TOWNSHIP: I/� /Y \ SECT( 1 t 1 1/414: S `v r, Driveway permits_ <br /> /�//� � �4: W <br /> - (state,county, r <br /> ADDRESS: <br /> (� r et/0 ,Sanitary per its <br /> CSM: et, <br /> __5-3 LOT SUBDIVISION BLOCK/LOT <br /> (public art) <br /> PROPOSED PROJECT INFORMATION STAFF REV( Fi <br /> PROJECT DESCRIPTION: /'�I e s �� <br /> S �/ d'a'/'"S�G�S /� / GG �'oning District -1" <br /> ►� This project i a n w buildi or structure. <br /> " p ) Permitted Use / <br /> ❑This project is an addition/alteration to an existing building or structure. �il <br /> SANITARY SERVICE: PERMIT NUMBER: ,. *dclit's <br /> 0 SEWER SEPTIC tc 2 0 35 3 I ng) ' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ' �� <br /> oodplain/ <br /> Shorelan• attach rent) &1 <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ��� 11 ErOSianContral permit <br /> BASEMENT: F !�/r�l !/1 1ST FLOOR: A 8 r ,� <br /> / 2 3 4, TOTAL SQUARE FOOTAGE: 1 (Slopes,diMiitbartce, 1/ <br /> filling/access} b <br /> 2ND FLOOR: 3RD FLOOR: <br /> g V <br /> ESTIMATED CONSTRUCTION COST: 'Review Laeattarr641 ey <br /> ♦ ♦ ♦ .,♦ ♦ ♦ /h� /{ and available options <br /> (Please round to nearest dollar) /5 S U (,f � <br /> oO4-' <br /> 1. The property i within 300 feet of a stream r 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland o IaocIpilaln on or near the property? ❑Yes gNo ❑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? Nlyes ❑No B4 , ,,... <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 ❑Don't know <br /> 7. Is this to correct a violation? Ili Yes ❑No <br /> 41 g; OO <br /> • APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► —► <br /> 545-112(4/08) <br />