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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME)EPN I c711. [,,,g 1 L - _ _ oning Status; CUP; <br /> OWNER ADDRESS (Number,Street.City,State,Zip) a Deed Restriction;CSM <br /> 3S$S .stir 4kA I j/ !! ° 'A( wt 5 3S! 3 _ Variance(# ) <br /> HOME PI-IONS CELL PHONE E-MAIL ADDRESS <br /> 4921 -OS64 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and 'ncludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> CtJ4-r 6 fr 1/ f&- /VDT jo,-r kir-e S,.04- Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> IM 2a Id. ‘)t 4-t-, ,R $S z jJ ti(tor•a 1A. <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> 1144.1)0L T'AJ C'L,53S4,2- 04(AO LC'Mt) ew( .5 35-4Z <br /> PHONE PHONE i. tte Plan approval from <br /> /CV-24 Z X17 sZ o8.-y t 7.-- 4 s 2 yip licable township. <br /> E-MAIL ADDRESS '-i ! E-MAIL ADDRESS <br /> coo. No1rJus'rh1T sus..C.4.--Cyr-r NeT 1vt rle.,rc s.c,, Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: tion of property <br /> kPARCEL A L s c)703-304_2 t2.7.-0 Q-1 ,..s-2-3 rontage drawn to scale. <br /> NUMBER — — — --TOWNSHIP: SECTION: �.riveway permits <br /> Q?__-_.- ---._---__.-_- 36 /4: S E _ /4/4: N j' (state, county,town) <br /> ADDRESS <br /> SS c'4 4k, Tit , J a-00A w( 53s9 3 ary permits <br /> • nita <br /> CSM: LOT SUBDIVISION BLOCK/LOT If (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION. <br /> 7 re ( a/Zoning District <br /> . 2 This project is a new building or structure. WYPermitted Use? <br /> Li This project is an addition/alteration to an existing building or structure. <br /> - — TI — �, o l Ad <br /> SANITARY SERVICE PERMIT NUMBER: I 1,. <br /> SEWER d!SEPTIC newt-, • <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> a tland/Floodplain/ <br /> — - horeland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) tij <br /> ionControl permit <br /> BASEMENT I1STFLOOR: T slopes,disturbance, <br /> � j, TOTAL SQUARE FOOTAGE: j ( p <br /> i — -- ---- filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ------ 2,�� <br /> t.. Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -1. 3 s-Ov OG , • 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? Li Yes o L Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No LJ Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? XYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes 'lo <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) LI Yes ' "No 21 Don't know <br /> 7. Is this to correct a violation? J Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />