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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 /> IY!/9 A) 17oin 4114 s O 0 • ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,Ciuttyy,State,Zip) 4/ G A Deed Restriction; CSM <br /> HOME CC�K CELL 4 fry L� E-MAIL ADDRESS 4iti ,8 rYfd7 Variance(# ) <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG NT NAME Cga� ACT R NAME <br /> If te, fee Al I .. Xi ck eo ppernoO ❑ Site Plan including location <br /> AGENT ADD RESS caliZRACTOR ADDR S of well/septic <br /> x737 C.14y N "! S 4/ 5I-7m- Rd <br /> (City,State,Zip) 1 .. (City,State,Zip) ❑ Setbacks <br /> C644-,�c Cie. (O s35 44-� ✓e w/ <br /> PHONE P NE ❑ Site Plan approval from <br /> 60 F cr73 /oho S' Cosa r 7 7 Z Li 102 applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 6 (_ N „ Q 13V9`1M r �) 41.671n frontage drawn to scale. <br /> NUMBER �P D ` �L+ vQ� <br /> TOWNSHIP: SECTION: 00 <br /> P t-eirstpot }S fe.vv..c s D i '/a: SW '/4Y4: IJ G ❑ Driveway permits <br /> ADDRESS: ` (state,county,town) <br /> x 737 c 01 0 Co a" e C Qt>-v.c. ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION ' STAFF REVIE] <br /> PROJECT DESCRIPTION: Z m <br /> ❑d FFLt� . to x�0 oning <br /> Distract <br /> . AThis project is a new building or structure. ❑ Permitted Uses= <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address , <br /> ❑SEWER SEPTIC (new/existing) } <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 4lletland/Floodplam/ , <br /> Shorelaod (attacttiten) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ 6CO 1Qn <br /> BASEMENT: 1ST FLOOR: SCf?Iitlfll perml <br /> T f� <br /> 4, TOTAL SQUARE FOOTAGE: (slopes, i tul!ba e,v filling/apcess) : �€'' <br /> 2ND FLOOR: 3RD FLOOR: 90 <br /> ❑..Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ ��d oo and available options <br /> (Please round to nearest dollar) ♦ ♦ --► ♦ ♦ --► , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No Ja D 't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes Ono <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <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) 0,s. aco '❑Don't know <br /> 7. Is this to correct a violation? ZYes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br />