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\ <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU •TOMER TO PROVIDE <br /> OWNER NAME '^ <br /> I,h 5C-VL-r4 I D r 0 Zoning Status; CUP; <br /> OWNER ADDRESS (N tuber,Str c e to Zip) <br /> 1 ed Restriction; CSM <br /> t r O�- k G LOl l2/ ariance <br /> (# ) <br /> HOME PHON -Q ) CELL PHONE( b ) E-MAIL ADDRESS <br /> 4q5-4 29' Z�Q-4 2 S' Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME C� CONTRACTOR NAME <br /> -_J/ ,1 S' Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE Site Plan approval from <br /> pplicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBERS ^ CURRENT ZONING: ACREAGE: <br /> PARCEL (n O („ �p 500 . 0 . E <br /> NUMBER vv VVV �"vvv 7 0 frontage drawn to scale. <br /> TOWNSHIP: �6-Y SEC I <br /> • 1/a: .S r 1/a1/a• S _' Drivewa its <br /> ADDRESS: y (S , ounty,town) <br /> � sI S r`trt , . Ile � . <br /> CSM: LOT .UBDIVISION ( Icy Sanitary its <br /> (pub' , private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: j . XC i x • ' d <br /> /t dO( o rte-. 4 b0. Lys S / foning District <br /> ❑This project is a new building or structure. Permitted Use?3 <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1:3 Rural As r s(rleW istin• <br /> ❑SEWER SEPTIC <br /> HEIGHT IN FEET: i 5 a NUMBER OF STORIES: (Not including basement) U Wetland/F plaint, <br /> 1 St( d (attachment) <br /> AREA TO NEAREST SQUARE FOOT: a <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> 0 ErasionCo�trol permit <br /> TOTAL SQUARE FOOTAGE: (slope disturbance ,-:,-,-',,ral <br /> Pen 13 rcl.. j j filling/access} v <br /> 2 D FLOOR: 3R FLuuR: C <br /> M U Review ,ocation`=Survey, o <br /> ESTIMATED CONSTRUCTION COST: and availa e o?tionS <br /> (Please round to nearest dollar) -'∎ ♦ -► ♦ ♦ —► $ ©o O f , :-, <br /> ' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 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? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes a No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if no e) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No VII Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 7 1 (Continue on Back) -► -P -∎ <br /> 545-112(4/08) p�. <br />