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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU'- OMER TO PROVIDE <br /> OWNER NAME <br /> �y n►12,. V. S o.,u e,,5- V Zo • g Status;CUP; <br /> OWNER IO15DRESS (Number,Street, itycs�t r Zip) � ) S3 el D ed Restriction; CSM ) <br /> Ix33 12: Q of�w¢ .) kor ariance # <br /> HOME PHONE CELL PHONE ��11 E-MAIL ADDRESS '' <br /> e7 - 575"7 0 "t 101 Wti o ) (Az X00 ao.C-cTW ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION ndt dudes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ak j ciAcA ,,I "T70 4i Si Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o ell/septic <br /> 1033 CR dele,,t) pr-- <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> � 01-� 635B <br /> PHONE PHONE ❑ to Plan agpfoval from <br /> (9 Z- Li/0 7 lica township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> iy :.,o If - " / () a r ,c, Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (h ttp://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: Elevation of property <br /> ❑ <br /> NUMBER <br /> UJ 11-/7/-0V/R-0 „Q? . 9'I 7 frontage drawn to scale. <br /> TOWNSHIP: ((,A, SE TI N: ,! <br /> pUV\ \C.=r VC- 17 '/4: 1- '/<'/4:� ❑Driveway permits <br /> t (state,county,town) r <br /> ADDRESS: <br /> '�� ( �' ❑Sanitary permits <br /> CSM: 1 12 5 • I LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> alw 611110kCIL S JV- QZocw\ IV oning District <br /> . ❑This project is a new building or structure. • Permitted Use? <br /> pfthis project is an addition/alteration to an existing building or str re. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Ad• s <br /> EWER rEPTIC (new/ex-ting) <br /> HEIGHT IN FEET: /)6 NUMBER OFFSTORIES: (Not including basement) <br /> ❑ Wetland/FI plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore) (attachment) <br /> (Outside dimensions including unfinished area,attached g ages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErosionControl It <br /> /6 4, TOTAL SQUARE FOOTAGE: 4, (slopes,dist ante, <br /> IN5g41 mg/acc s) <br /> 2ND FLOOR: 3RD FLOOR: I <br /> Review Location Survey (k, 1 0 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ^� 00 and available options. <br /> ill"`"' <br /> (Please round to nearest dollar) ) lriJ� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? f Yes glo RDon't know <br /> 2. Is there a wetland or floodplain on or near the property? .1 -s ❑NO Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es a'Jo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes n o <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 ►i/,■o ['Don't know <br /> 7. Is this to correct a violation? Dies "i2 o <br /> APPLICATION MUST BE SIGNED <br /> (::; (Continue on Back) <br /> 545-112(4/08) <br />