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s---/ <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Ai I C((4 ot"" A . Gent khoLI oning Status; CUP; <br /> OWNER ADDRESS (Number,Street.City.State,Zip) Deed Restriction; CSM <br /> 3Via. 5iivez £ g_164& 40- Varian e(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4 c - 8 - 8(D &a/de Woe, e 41O,elm Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State.Zip) (City.State.Zip) etbacks <br /> PHONE PHONE n Site P a proval from <br /> applicabl wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor p s to s ale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane-wi.us/) a f ro <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elev ert P y <br /> ❑PARCEL '1 n /��_ +� front e wn to scale. <br /> NUMBER 07.19\ J✓a300f - . -ft- , 1 g• f l 4 <br /> TOWNSHIP: SECTION: <br /> D 111 3© 1/4: kl w 'Ai/4: Li(v n Driv ermits <br /> ADDRESS: (sta e, co nty,town) <br /> n Sanit r rmits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (publ vate) <br /> tor "l Kot4 46(y14.1-5 <br /> PROPOSED PROJECT INFORMATION /STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> DE -- 60-C N rl oe-1 IC, X L.14honing District <br /> ❑This project is a new building or structure. er itted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: RUra A-•• -` <br /> EWER [EPTIC (n r., existing <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1—i--4 nd/F dplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> hor d (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: I 1ST FLOOR:Q EGOS C trot permit <br /> i l� 1 TOTAL SQUARE FOOTAGE: y (slope , .sturbance, <br /> 2ND FLOOR: I 3RD FLOOR: /acce ) <br /> 1 %. Revi tion Survey <br /> ESTIMATED CONSTRUCTION COST: .. ♦ �1 ✓ and I le options. <br /> (Please round to nearest dollar) tTS�. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes giNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? nYes ENo ❑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 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) Dies rlo ❑Don't know <br /> 7. Is this to correct a violation? EYes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —+ <br /> 5.15-112(elo9) <br />