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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> - PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER E <br /> 01A. rV`.l.'1r\ , ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City, Jf Deed Restriction; CSM <br /> 61 CD -4-1 itiv,e tom- L/0t5a/ t.).1- gasg Variance(# ) <br /> HOME PHONE CELL PHONE E- A'IL ADDRESS <br /> ''S r (04- <br /> (64 l a t► -�- •n `� Be. �,✓t tr /anc1<-hc-/ <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO RACTOR NAME 4 /{ <br /> „/n , 34( e J11j ``L ❑ Site Plan including location <br /> AGENT ADDRESS CO TRACTOR DRESS of well/septic <br /> 67od /A1,41 <br /> r �- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> L140.501 (C' 1 53591 <br /> PHONE PHONE ❑ Site Plan approval from <br /> OOt 7Z° al v y applicable township. <br /> E-MAILADDRESS E-MAI •DI�SS /./�/'-7 ❑ Floor plans to scale KAI It <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.aane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL `�_��_ 1 p� _3� ' 3 frontage drawn to scale. <br /> NUMBER J 115 <br /> TOWNSHIP: SECTION: 1/4. 1 1 CI Driveway permits <br /> 4J �� s /a/a: /U (state,county,town) <br /> ADDRESS: <br /> 6 706 ffA'v&/?c L•-!A. ISO / 4.=-1-5,--57j ❑ Sanitary permits <br /> CSM: 1 I LOT l SUBDIVISION BLOCK/LOT <br /> 041- (public,private) <br /> - h <br /> PROPOSED PROJECT INFORMATION STAFF RE1,,,,-, / <br /> PROJECT DESCRIPTION: 2` <br /> (57-1 .--1 .1L- i=4-%•k■■,-S ❑ ZaningIStnet• <br /> . lirt his 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 /> ❑SEWER ❑SEPTIC (rtew/exlsttng) :; <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 1 ❑:VVetland%F(oodplal , <br /> Stioreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Erit) 16nControl permit <br /> BASEMENT: 1ST FLOOR: ' �g <br /> �24 720s( ,, TOTAL SQUARE FOOTAGE: j (slopes,distulrl ance� , <br /> .,:,,..,...1.,ing/ac;ess) <br /> 2ND FLOOR: 3RD FLOOR: 72-0 �/ <br /> �r Q Review Locatio Survey <br /> ESTIMATED CONSTRUCTION COST: 00 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 IS1 No ❑Don'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? '6IYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 4ires ❑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) EYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes to <br /> (-1 APPLICATION MUST BE SIGNED <br /> Qt) (Continue on Back) "--0 ♦ -► <br /> 545-112(aloe) O <br />