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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME '<Ali jf(,1j�I/i4m G. '<Ali L J LL C. ❑Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State Zip
<br /> Yd 99�) {/✓/ I y Deed Restriction; CSM
<br /> HOME ��� CELL�HONI E-MAIL ADDRESS Variance(# )
<br /> (00,x' no- &j -/ 3K4AL -e l✓k cow siruako,.t/. ea.- ❑Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME A CONTRACTOR NAME /
<br /> afi r,s O /e/&o,-`ido,AP,✓ Alb ytn�p.' del 1{4r/,S�'.yr ❑Site Plan including location
<br /> A NT ADDRESS CONTRACTOR ADDRESS l of well/septic
<br /> /0) f. A3j a. 11 "es e &a re. la
<br /> (City,State,Ziq) (City,State,Zip) Q Setbacks
<br /> r/I,S-Ai, ti,/ 5 3 7/3 Ai 9-el,p.,.ti car 5.37'3
<br /> tP PHO E ❑Site Plan approval from
<br /> & ) .7m' - 7700 �/„0 0,)7/-7i O applicable township.
<br /> MAIL ADDRESS E-M IL ADDRESS ❑Floor plans to scale
<br /> • tl.ew ' ✓�0'14.sOw 4c1,,,,, co.,,,.. s '4.ICwS/,JV' ' ,®lq 'Uesi1©o Lowy
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property
<br /> ❑NUMBER 0103 ©83-glop D C-a a?y. 5 frontage drawn to scale.
<br /> TOWNSHIP: / SECTION:
<br /> �,/;alc(likn/ O 1 1/4: S W 1/41/4: N i.J ❑Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> or Pr',,r,iSP S,5,,' /,9tie ❑ Zoning District
<br /> . QThis project is a new building 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 /> EWER [EPTIC (new/existing)
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> 3 5' ❑ 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: 1ST FLOOR: r-, ErosionControl permit
<br /> 4 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance,
<br /> filling/access)
<br /> 2ND FLOOR. 3RD FLOOR:
<br /> 30 0.0 ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: $ 6 t?0 U and available options.
<br /> (Please round to nearest dollar) '♦ ♦ --► ♦ -► O
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes pIGo ODon't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 3( ['Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? 2fes ENo
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? s QNo
<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) EtS'es QNo ❑Don't know
<br /> 7. Is this to correct a violation? [Yes OP4'o
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -+ ■ —►
<br /> 545-112(8/09)
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