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7P,IS --, --.g . <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLE M E ` to e`' A a p <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> W i W.-)A 44 1--ANNCC I <br /> Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,zip) Deed Restriction;CSM <br /> 4 6 35 Hic-,9 f=I e Lo o , /VI(D pL�j c,.../ , W , 5 3 5 6 2 Variance(# ) <br /> HOME PHONE CELL PHONE E-MA LADDRESS <br /> 60$ 8 it 0033 a i 11, 1 a,t�-%ec, J td is .net ite Plan drawn to scale <br /> AGENT INFORMATION ICOIITRA:CIOR INFORMAAIION and includes dimensions <br /> AGENT NAME - CONTRACTOR NAME <br /> S 4-ml f Ulv/r/6-1' 5,9", 6" ,5 p i-1n/>s7. ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) AI Setbacks 3V-50° <br /> PHONE PHONE Site Plan approval from ,,v4-... . .wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> i7 loor plans to scale <br /> PROPERTY LOCATION INFORMATION (http: ac :essdane.co.(Live.wi us j al Elevation of property <br /> PARCEL NUMBER: CURB NT ZONING: ACREAGE: a pe <br /> LI PARCEL 0-0?-043,-2-Z Q 7 _O _ 1 3 S t0 frontage drawn to scale. <br /> NUMBER 0 <br /> TOWNSHIP: / SECTION: ,�/ A <br /> 5-i l 00 L 110"/ 0 Li '/4: Ski 14%: ( v Driveway permits � /�`/r`�JL <br /> ADDRESS: (State.-COUni1{r 9)v ' <br /> at is H(c o pt c D iAV /,r ,pp L.e-ye a9 / 1J l , S 3S 62 ati Sanita .,- s E-#Lekle, <br /> CSM: LOT SUBDIVISION w,;�d5 BLOCK/LOT .l) <br /> 1 lsetr2/,i(,. 4 tau <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /j o;;,> •--,pp ) p d,/ j Zoning District A <br /> . ❑This project is a new building or structure. %Permitted Use?/4 dK 71-rD <br /> this project is an addition/alteration to an existing building or structure. c/r/ <br /> SANITARY SERVICE: PERMIT NUMBER: Rural •-._.: <br /> ❑SEWER ..SEPTIC (n: ,r sting <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) " y'••plain/ ve <br /> � " achment) w <br /> ) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porch:- �� <br /> BASEMENT: ( 1ST FLOOR: n�sionControlperm �-- <br /> 2t�' '��� v�� j TOTAL SQUARE FOOTAGE +, (slopes,disturbance, `J 1 <br /> 2ND FLOOR: `/�_` 3RD FLOOR: �` u�v full /access) ,/��f / <br /> �� �— a� 4 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -i -♦ i ♦ ' and available options. <br /> (Please round to nearest dollar) S 0 0 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes -Mo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes -tirNo ❑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? es ❑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 I*lo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Xr4o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -. -, -► <br /> 545-112(4A8) <br />