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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME is%. <br /> yak)iel or elact_cLi et- Aq 'SUyl <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2yCZ 8 � '..Y St1�.�. f Variance(# ) <br /> HOME PHONE j CELL PHONE E-MAIL ADDRESS <br /> o8 -S-73--(14-i3(4 ' 6n$-5i5 --'10/ 5K ki or 7 a)Zt'kc' • tc'v" ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e.r`n t 5 ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ZyZS d t 5Cn /411°e. <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE j Or r\ , 1, I 5'3 6$ ` El Site Plan approval from <br /> PHONE PHONE <br /> Q 8" _JC. i 6 — 9 7 0C) applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r}, OH ec rccr t e Ot-r ti 1 .ctovv., ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: Li o / ACRE`A�GE: frontage drawn to scale. <br /> ❑NUMBER �`/(/ L,�� G � . i1( ! V . <br /> TOW SHIP: SECTIOy; ❑Driveway permits <br /> On f ��` 1�4��4 (state, county,town) <br /> ADDRESS: t„ <br /> •s 4 c Z PU oe(f 5f. S j )ti ' k hpy1 , ti.2 I J 36.;g 9 ❑ Sanitary permits <br /> CSM: LOT SU1DIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Sj 1eLd V_ 10 ct CP I Li 0 Yi9 ❑ Zoning District <br /> . [XiThis project is a new building or structure. Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> EWER F EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> 1/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ErosionControl permit <br /> BASEMENT. 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 2_C y <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: / and available options. <br /> (Please round to nearest dollar) —I. —I. 6 r C <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? r]Yes ENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ao EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? lares ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des [iNNo <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 No ❑Don't know <br /> 7. Is this to correct a violation? M es No <br /> `■+o k-ii OVA <br /> V g 4 APPLICATION MUST BE SIGNED <br /> 545.112(4/08) <br /> tf (Continue on Back) <br />