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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 /> STQ U Q.n A 02,50 r1 _ ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 36237 VIC-K1 ,r}N Al Sy n'), J4r r.✓Z 535102- variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6e-g- S o— 06-1S' ne.W-r a. 0 cKw4e'. ntT ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /)')p 17 t4- }�crriax►t,.praerne N-- ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR/CD DRESS of well/septic <br /> 17o3 R osS 2t) <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> C07-TAVZ thrvL,g_ (-,)? Sr-33-X) <br /> PHONE PHONE ❑ Site Plan approval from <br /> Zpa - 2 jt - (D F°8 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Cr G;4- 0 1407 ww.,L,Ccx.. ❑ 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 frontage drawn to scale. <br /> NUMBER 030/D70$-3D1 tiSG3-0 W-I <br /> TOWNSHIP: SECTION: <br /> • <br /> 3 0 1/4: N iE 141/4: S//,v ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> E (public,private) <br /> ch�rr woc� 'v-ems <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 1 <br /> f4 8a "TO Co A f P - 0 Zoning District <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use. <br /> W This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address ,w <br /> ®SEWER (lew/e1St[ng} <br /> HEIGHT IN FEET: C NUMBER OF STORIES: (Not including basement) <br /> 10 V I Q Shorel„., ,,, plaint <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (atefimen) `. <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Ervsl2Conf>of permit, <br /> BASEME 1ST FLOOR: d4 <br /> y ,[�I�ni,,,,� • {i 5 � � TOTAL SQUARE FOOTAGE: ,l, CSCfSpE.t'�` �IStU� �n�C�i 5 <br /> ✓ fining/access) V <br /> 2ND FLOOR: 3RD FLOOR: 9- r <br /> / O ` <br /> vle =acativl Surrey <br /> STIMATED CONSTRUCTION COST: <br /> -∎ -0 - --0' -► fa/ and available options <br /> (Please round to nearest dollar) COO ,. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes VI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes W No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 53 Yes 0 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes VI 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 '❑No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes 0 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0 —► <br /> 545-112(4/08) <br />