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. ZONING PERMIT APPLICATION w�w.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /' <br /> 6/1,4 (�j k f`"'\ ©'Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> Iv 7/f 4/ i♦'- Al 4 e i- . ' ()f-o r 61.1/ c2S`-r�' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADbRE S <br /> 3'; - •. 03 t.- - >7 0 CMG 6/4 's'-t i a Ad°' G'1' L 'Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ,� <br /> en (4i.-!J 674.j%,,,,, Li Site Plan including location <br /> AGENT ADDRESS �v�Q r CONTRACTOR ADDRESS /� A �,/of well/septic <br /> 1(26-1157 tr ' '�h aiA I�7/ Z-i/ VII0/- /ct e /^l LV Setbacks <br /> (City,State,Zip) Q .5 U (City,Sta Zip)> <br /> PHONE PHONE arSite Plan approval from <br /> ' applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ,-�,/ <br /> �. . <br /> �: � • , /to ) et X00. 6,w., L( Floor plans to scale <br /> Lri <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) L3 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: 1 ACREAGE: p pe <br /> NUMBER 064'/09/0.-�2 93-f39;) , ,C s-Y p frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> W '/.: s w '/+'/<: 2rDriveway permits <br /> ADDRESS: �),adsa, o 9 (state,county,town) <br /> 0 QzCOOt■ CV, N4.512,040 C W-t. S' S' D- [Sanitary permits <br /> CSM: LOT SUBDIVIS ON BLOCK/LOT <br /> (public,private) <br /> vv <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /vew (1ytl�Truc/f J e T %Lcy`Gf.=J? 4l igu..�"el/Mill 4�. II ing District <br /> . ''This project is a new building or structure. ermitted Use? <br /> ❑This project is an addition/alteration to an existincbuilding or structure. <br /> SANITARY BERM: PERMIT N MBER: ❑ ; - Address <br /> iia SEWER ❑SEPTIC 6(f ili,xisting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> .,2 V / % Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorelend (a - M ment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ Erosio• 'ontrol permit <br /> BASEMENT: 1ST FLOOR: <br /> / yj2 3 /8 / j TOTAL SQUARE FOOTAGE: j (SI•-" ,disturbance, <br /> j • mg/access) <br /> 2ND FLOOR: 3RD FLOOR: ;.-4 �� <br /> S 3;.-4 9 R Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ■ ♦ -11 ♦ .0. ♦ $ sJ a G' () <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes flo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the prop rty? -Ses ❑No ❑Don't know <br /> 3. Have you talked with the township about your proj ct and are they in agreement? es CI No <br /> 4. Has there been a zoning permit issued for this pro erty in the past 5 years? ❑Ye ,esl No <br /> 5. Is this project associated with a rezone/CUP/varia ce(petition/appeal# ) (le a blank if none) <br /> 6. Is a location survey required? (see reverse) i )i Yes selo ❑Don't know <br /> 7. Is this to correct a violation? j ❑Yes , No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —0. -* <br />