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I <br /> ZONING PERMIT APPLICATION .countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> %Ct.i1 I. C e-, 6 h el ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> qg - n e.-ti ` e Ic_P_e� t-.--r--__ /YI e.A.6(..4 Scn- w I 6-3-7 13 Variance(# ) <br /> HOME PHONE arc4-1 CELL PHONE Qx01-4..2-- E-MAIL`ADDRESS <br /> £00g- ,A55-S8(o`d t#t' - .4(o(' - ?3C ❑Site Plan drawn to scale <br /> AGENT INFORMATION j CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> *S4-2.1.K..b-& Y-)-c yt o_5 r'l.o (c.,44c i. 5i- r 5 eJ, Tho ❑Site Plan including location <br /> AGENT ADDRESS CONTRCTOR ADDRESS of well/septic <br /> 3,A9 Hui y. (3 Al-b-1.2.7 0-5L)C r n t-k!(Lk-1 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> LL)I5c -nsi,A 6R fa3 tA.1 I 539w=J Carl dc..Lo-c- 1 5ZI937 <br /> PHONE PHONE I ❑Site Plan approval from <br /> (Fcg- X54 - 834 /c <br /> -115- ,. --1( - I `i I a- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> tucc c, , • r4t-e e.►i Lk ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) ID Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER Ct7 n 93'5,9C ' 6' -- / /c.),_ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -row`� c� /Yl cue'Ev" -. S <br /> : %,/4.: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> LN,. /-4-c nuzL u c_k-eL, Lc:_.,t_11-, MOL 3.cn g (.c,.;I S 31 l 3 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> cjcja mcR.cG��,l rnNP <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Rep I a_ck. s I th-r 51.-Ici l e, Lti GU_ Ii --,uz., L.,11 .i e 4,; I q X s h fyk,tie; Cl Zoning District <br /> . RThis 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 /> 1-. EWER TEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> l 0-rt_A. ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, ttached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 0 6'91 j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: I filling/access) <br /> 0.0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ••► ♦ ♦ ♦ ♦ $ and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 100 feet from a pond or lake? ❑Yes Dio ['Don't know <br /> 2. Is there a wetland or floodplain on or near the pro erty? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 13 es to <br /> 4. Has there been a zoning permit issued for this pr perry in the past 5 years? DYes [vlo <br /> 5. Is this project associated with a rezone/CUP/vari nce(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ✓ lo DOon't know <br /> 7. Is this to correct a violation? DYes E Vo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(8/09) <br /> 1 <br />