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Z <br /> x . <br /> IS <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> •'77M ;42/140 AW/ Zg' /, Ei Zoning Status; CUP; <br /> OWNER ADDRESS;(Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 : �//y /31/ ezig otowGe l�/Z. 573-c),3 Variance(# ) <br /> HOME P1110 CELL PHONE E-MAIL ADDRESS <br /> .,OX . 6 A SY3a Site Plan drawn to scale <br /> AGE,: INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGE NAME CONTRACTOR NAME <br /> A/�f /✓/A QrSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> , ,r/���SD/l/ lit/ clOYo? Lor/Do.✓.,6? <br /> (City,State,Zip) (City,State,Zip) lErSetbacks <br /> PHONE PHONE liikte Plan approval from <br /> 6,0y. -7/07 — 8633 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS ,/ <br /> sd Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.daneawi.us/) levation of property <br /> PARENT PARCEL NU BER: CURRENT ZONING: ACREAGE: p p y <br /> 0 NUMBER a a y�o7Ao1„d61--8. ,g- 5 y3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: ,`� <br /> ,OJEE,eetezD .369 14: ,(JZ 141/a: /V nveway permits <br /> ADDRESS: state,county,town) <br /> 3313 Irv,' /3 / <br /> Sanitary permits <br /> CSM: LOT / SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW` <br /> PROJECT DESCRIPTION: <br /> AnQ//%a/✓ Zoning District <br /> ❑This project is a new building or structure. Permitter Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMB 0 Rural A€ <br /> ❑SEWER ®SEPTIC /() (new l � W F <br /> HEIGHT IN FEET/ NUMBER OF STORIES: (Not including basement) 1N1 <br /> off/ �lo etiart dO*On/ ; <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) if QC , <br /> npermit <br /> BASEMENT: deA6/4,5,4QE 1ST FLOOR: <br /> /6 Sa#7 /_ it l TOTAL SQUARE FOOTAGE: j ,4 , ' a 7,17,,..,;,;;.- <br /> Q� 7 (D Sri ss) <br /> 2ND FLOOR: bald t as' RoteN 3RD FLOOR: "7 <br /> 34o a-toe,4 foe cv4 SToe�4CoE � o <br /> Fievtew Looati :;purvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► ♦ ♦ and avail ble xt ons <br /> (Please round to nearest dollar) $ 5Q o0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IgNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a No ❑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? ❑Yes ia No <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 allo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes .1SiNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —0. -0. <br />