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'' <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1<EI..Y A FKOPEL_ ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D�ER�O1 t \_ /1 Deed Restriction; CSM <br /> !(�5`-! 4,M M Eh N �av l 5353L/ Variance(# _ _) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> MPtgl<Ll lKt goiLDEKS ()JC., ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3`1,35 K. M11-WwKEE 5T <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> ....i P<NV-5V)11E. W 1 5351.1(p <br /> PHONE PHONE` ��OC18 _ 751 C78 `'� ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane-wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL O L(Q/OCo t z--•3zs{-952.0-o K H-l Z.•oo C> 1 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> CI-1 Ki5-1l totil, 1 r , , 5 E ❑ Driveway permits <br /> _ 3?_ is— ---- i is---- <br /> ADDRESS: (state,county,town) <br /> HC MELI KO <br /> ❑ Sanitary permits <br /> cSM: C5 LOT BLOCK/LOT <br /> 11113 6'7/ze-vi °F (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF,REVIEW <br /> PROJECT DESCRIPTION: <br /> PEW 5 t I4&LE F4MI14 iZESIDENCE ❑ ZoningDistnct <br /> ®This project is a new building or structure. <br /> CI Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER:r ❑ Rural Address <br /> ❑SEWER SEPTIC 1 82.3 Li (new/existing) <br /> v <br /> 5 TIGHT IN FEET: I t 0 ( t NUMBER OF STORIES: (Not including basement) <br /> 1g-5I� 1 A t $-81i = 2.7,E 1 ❑ Wetland/Floodplain/ <br /> l,, 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: <br /> ❑ I:rosionCCntrol permit <br /> 1881 I BB I t t 9.5 ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: SRD•FLOOR: Ztp 7 ct /J /�(, <br /> filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ Q OOH and available options. <br /> (Please round to nearest dollar) $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes rSI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Si 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 ❑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) ❑Yes ZI No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Ei No <br /> tic(PC) D,0 7 i APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —e --e <br />