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-P 7 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Ru C,'.1 i4 L/1/.'0. ../.9r-a Al dck_ ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street.City.State,bp) Deed Restriction;CSM <br /> --78 C £ A//.57 #-, - C74- Ve r-o 1-76( a-24 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 533 <br /> if: -83/-630 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /-ia,•+7 D'C.)' ) �� ra(Al 0ci'/ <br /> 4 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR'ADDRESS /� "t%-pf well/septic <br /> S3 2-/ 1/08 f'S R 1:1 Setbacks <br /> (C7y.State,LP) (City.Sate.Zap) �J <br /> PHONE <br /> ' ' c ow � 537/8 Site Plan a <br /> ❑ approval from <br /> Gee-8_3E3-6 ya) applicable township. <br /> EMAIL ADDRESS E-MAIL ADDRESS F,a sip.on <br /> e sah i-.•7-r , . f ❑Floor plans to scale <br /> ar .r� �C�� <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PlaiPARENT PARCEL NUMBER CURRENT CURRENT ZONING: ACREAGE: frontage drawn to scale. <br /> NuIPAICEL4BER 03617070$--/93-6/3/-A R-/ <br /> TOWNSHIP: SECTION: <br /> 4 7 / ON '/.: S co %IA: S F ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> -78670 Co b'j/t s74'0 ( Of- ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> // /6/.!)re:?,.-ie Vie <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ren40 esis ..i 3/ass pct1C ran.►-� red ❑ Zoning District <br /> t� /ace,. w,th ��a� ,,,, � <br /> - ['This project is a new ilding or structure. 9/'/-Sca s on t ti:" r?ocr n, S a.r,e_ <br /> ❑ Perratted Use?z e 0-,c e k,i •o,9 ..oo.+ ,, <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> HEWER PEPTIC (new/existing) <br /> HEIGHT IN FEET:// Y I NUMBER OF STORIES: (Not inducting basement) ❑ WetlarxUFloodplalN <br /> AA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ EIOSionContrd <br /> BASEMENT: 1ST FLOOR: - p <br /> a 3 O 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> R <br /> Z 3 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ and available <br /> (Please round to nearest dollar) -"� "♦ -'6. "'� '� .p z 8 00 p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yes [lo [pon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes DIo IDDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes IDNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes OVo <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 alo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ONo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(8/09) (Continue on Back) -+ • —► <br />