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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O ER NAME , j/ <br /> le! - vt)- X'e EL (leg_ ❑Zoning Status; CUP; <br /> OWNER ADDRADDRESS k Ne CI 12Cjam' 49 14ceb W .5357,? Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (Q* 3,-to SYO(5O,-0235--3V10 1 / c• I yea_ A 4; • ("Cm ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRAC'iOR INFORMATION and includes dimensions <br /> AGENT MME A CONTRACTOR NAME . <br /> 1'(&`l tA0/0511 11-0C1-1 0/0 keII l_o�vsf ems' ►C``) ❑Site Plan including location. <br /> A ENT AD SS n ,/ n c� CONTR TOR ADDRESS RD <br /> of well/septic <br /> 300 10 v i0 u.wGQ.� V i e iJ RD 3002(0 01ovouc�s 1/i eLd D <br /> (94/,State,Zip) (City,State,Zip) El Setbacks <br /> 6,i.Le #0 cc buds 535/7 QLue 1,4k aa...5 41153577 <br /> PHONE /� PHONE L ❑Site Plan approval from <br /> ,1, a U�' 71p2 —66-9 ? 66g_ 71,9 - (as'cl 1' applicable township. <br /> E-MAIL ADDRESS / E-MAIL ADDRESS / <br /> 1/ , - .0„)$-'"g L i'r/e,co" k- 11 ..,p�5-1 7 1-t,'- , eD41 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL ©/,,d 7 1 7q_g�1j-_v A,' '� , ( frontage drawn to scale. <br /> NUMBER VV <br /> TOWNSHIP: ^ n t� L .A. SECTIO <br /> Q-v'�, J�� ,�4: S �- ,�4,�4: El Driveway permits <br /> SPILL'`' 0k. /�,, t 'y- 7 (state, county,town) <br /> ADDRESS: 3 5- L wc) G toe �, /,1ote� wl 535/ <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> / 0273 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: p�, n <br /> /l1 e.,) 5?"51 e C,441)(6, s l OS e,�c e— ❑ Zoning District <br /> . !/�This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: CI Rural Address <br /> EWER REPTIC /3-020/4v- 0Od&O (new/existing) <br /> HEIGHT IN FEET: �r NUMBER OF STORIE : (Not including basement) <br /> a 1 F+ & ado ❑ Wetland/F000dplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> 7 <br /> 1?0 35-60 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND OOR: 3RD FLOOR: <br /> 5-9801 / ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ -► ♦ ©od ` and available options. <br /> (Please round to nearest dollar) D <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes lalo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Ilo <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 Elo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes in No <br /> � <br /> c <br /> I 6 -- O 2.. k.APPLICATION MUST BE SIGNED <br /> fc 2 t/ (Continue on Back) -+ ♦ -9 <br /> 545-112(4/08) <br />