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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME 6 ��
<br /> ��� ,644/4,-) o'` C � ��//4/`) ❑Zoning Status;CUP;
<br /> OWNER AD RESS (Number,Street,City,Slate,Zip) Deed Restriction;CSM
<br /> (3 /O Gov,..-j y /244-d y`
<br /> A-d OA-746 G/ 7/, A.•e ,�`3,re3 Variance(# )
<br /> 110ME PHONE CELL PHONE E-MAIL ADDRESS
<br /> v -69)6 .__.03733=d.gi'ak N/ [✓]Site Plan drawn to scale
<br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions
<br /> ■ AGENT NAME CONTRACTOR NAME
<br /> e`t 6 6f ti j) 6/i :.+ /2/,ti co,JJ fl c.7i c), D Site Plan including location
<br /> VI AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> saw S .-;c ✓L 0GE Tot.G ? Pja s n^E T
<br /> (City,State,Zip) (City.State,Zip) Setbacks
<br /> r-I;d0,47.1mi wi 5 s-de- A-)51.0 (-It ethr w i 573 i
<br /> PHONE 6Ar...m 6 PHONE / ❑Site Plan approval from
<br /> GoL'- fa--O 6�4c=u 33�-/� �„p—JT —Y/0 j applicable township.
<br /> E-MAIL ADDRESS E-MAIL` ADDRESS
<br /> O
<br /> 1,N Ciiiiii4 # / i, um to ,, 0 G sjf rd ,N/T [/Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) [✓ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y
<br /> PRCEL � g/NUAMBER o9Q�//39 �0 � .7 frontage drawn to scale.
<br /> TOWNSHIP: SECTION:
<br /> /CD/ 471/4/ 1,,,,/ S�d2 1/: -1/4%, ❑Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> y/C) Coves'" ,)/ ,54-ti k- U_ J , w/ 5-33—(5'3 unitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> /0"06 S'q/- fl AO(i)i / 1 ())U ❑ Zoning District
<br /> . ❑This project is a new building or structure.
<br /> ❑ Permitted Use?
<br /> 12fhis project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address .
<br /> EWER ra<PTIC (new/existing)
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement)
<br /> P ❑ Wetland/Floodplain/
<br /> Shoreland (attachment)
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches)
<br /> BASEMENT: 1ST FLOOR r---, ErosionControl permit
<br /> j/4-( L 'c� �/j 6 , TOTAL SQUARE FOOTAGE: j (slopes,disturbance,
<br /> 2ND FLOOR: �'W 3RD FLOOR: v 7Q Sling/access)
<br /> ,�``� a-s (3 611) -c /0,3,3'
<br /> JV ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ and available options.
<br /> (Please round to nearest dollar) $ , L0 , '0 0C
<br /> .i --' v, e:_ , 4,„. i 5r tAtt fDo 44 /-4..,P64 :911
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Oyes slo []6on't know W
<br /> 2. Is there a wetland or floodplain on or near the property? ,,., Dies Gtio ❑Don't know
<br /> 3. Have you talked with the township about your project and`are they in agreement? Dies o
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes EliJo
<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) , s y: :.l.4a` . ;..._; Yes o ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes 40
<br /> APPLICATION MUST BE SIGNED
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