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lobs <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OVMR NAME <br /> a , ' 111:,, I"-0 /O Zoning Status; CUP; <br /> OWNER DRESS N ber, eet, ate,Zi ) <br /> � ) �f a ece tm /,'/ S-33-g3 Deed Restriction; CSM <br /> q�(`� V W Variance(# ) <br /> PH•L E i rELL PHONE E-MAIL ADDRESS <br /> di, % _/i, K Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION -nd includes dimensions <br /> AGENT NAME CONTRACTOR NAM e <br /> C QCI (I YU i` IG� n -i4 Site Plan including location <br /> AGENT ADDRESS CON CT D ESS S, of well/septic <br /> (City,State,Zip) (Cit , te,Zip) ��� � Setbacks <br /> PHONE PHONE A Site pproval from <br /> 141100- 3T \ appli township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor pia tO scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURB JTZONING: ACREAGE: Elev 'o of property <br /> ❑ PARCEL �/ ©Y,.2�/��1/0-g IO I I fronta drawn to scale. <br /> NUMBER l.�j / <br /> TO IP: SECTION: C <br /> .�,�-LO n 4 Sw X 1/4: N L '/41/4: Driveway p its <br /> ADD E s: /� (state, nty,town) <br /> oZ Si(\ ge/yii /e/rO o A Sa 'ta rmits <br /> CSM: LO SUBDIVISI•• BLOC 4 • <br /> (pu ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D RIPTION: <br /> �P oA (G 5e---- t2 r�. <br /> e Zoning District <br /> . lai This project is ew I:Ctf(ding or structure. 4 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT N ER. 4 Rural Address <br /> ❑SEWER SEPTIC N (new <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> , AWetiand dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shovel (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) zia Erosion ntrol permit <br /> BASEMENT: 1ST FLO <br /> + TOTAL SQUARE FOOTAGE: 4, 1 (slope disturbance, <br /> 2ND FLOOR: 3RD FLOOR: flIlln CCeSS) <br /> 1 view Location Surve <br /> ESTIMATED CONSTRUCTION COST: Q� •D •and available options. <br /> (Please round to nearest dollar) ♦ --► ♦ ♦ ♦ ♦ $ 0 b <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? CI Yes E{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? AYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 0 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) 1 Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes liQ No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► —► <br /> 545-112(4/08) <br />