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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 /> D&v r8 C.-tarp,eJ Qevil keJl 1-0 t+ZI.'eel 0 Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 51-09 ( ,Qv9 dtFe Si-• f h-L ur5 wr, 5-3 i 1 I Variance(# ) <br /> HOME PHONE I CELL ONE E-MAIL ADDRESS <br /> ( -a 14-E'S I- (oog- SIC-/Sas . 40 14 z.'t_n - 4,t ao•Coot^ [Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONT CTOR NAME <br /> plot filet —19 14 7-I tV` 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDg ESS of well/septic <br /> ,51-01 (Aka-r30-1-c- . <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> ei{zt46u,r9 , Wi s 37-1 I <br /> PHONE PHONE 0 Site Plan approval from <br /> ( oS— (aq S- $a I I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> f i TGL t$?33 u r - o. t od•(-DM [Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: i ACREAGE: El <br /> 0P RCER 0110—3s .-,(03-1-0-o re-Sldenl i o.( ( aL.crei frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 510ov %;bfl. Gr.64 e. 56 '/a: 'V IN '/a'/.: 3 S ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3Com C/0¢4Ce,o D¢4..te <br /> El Sanitary permits <br /> CSM: LOT SUBDIVISION 1 BLOCK/LOT <br /> 2 1 .0 g A ri l 141 1I S (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: n' n <br /> 'V�,to its 112f,off- CO S1r)C-I oV ❑ Zoning District <br /> This project is a new building or structure. <br /> p 1 g ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER JEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached gara•es and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> ,,4;414�1p't3i 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> S/ d til ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ / 000 and available options. <br /> ♦ .+ .•(Please round to nearest dollar) QQ <br /> If 1•l3a:SC' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes EINo IDDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes o �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes '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) RlYes Elo [Don't know <br /> 7. Is this to correct a violation? [Yes I'lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —0 —► <br /> 545-112(4/08) <br />