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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> ov ER NvE / �,/ <br /> gE / , [� &LE PI,F�" 5 siI Zo ing Status;CUP; <br /> O NERADDRE (Number,Street,Ci ,State,Z' ) eed Restriction;CSM <br /> 6 70 1 ra p k( X P Pi4/1f)- w-w5 915-3- y ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4i4— ` —co)2. 6od-W ', -1160 64;. 'CLEPEA/ CP(-ti, , (-oil 2 ..ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> (.it" -7 e -i) CO<,J/` 0 .v, .Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS a of well/septic <br /> I.a 070-t- d77 -?/��A...4f <br /> (City,State,Zip) / <br /> (city,Stateff Zip) T _ Setbacks <br /> Z----QC-4 / 4-1 535-5-5.- <br /> ❑ <br /> PHONE PHONE to Plan pproval from <br /> (CSS - a 7y -j? ppli le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Fl or plans to scale <br /> PROPERTY/LOCATION INFORMATION <br /> (http://accessdane.c o.dane.wi.us/) <br /> PARENT PARC LNU R: I U ENTZO ACREAGE: ation of ro <br /> e <br /> ❑ d Q 1 7t, ` frontage drawn <br /> tale.NUM ER <br /> TOWNSHIP: a SECTI : <br /> k t' � 1/4: N v ' . 1/1/4. N vj ❑Drivew permits <br /> ADDRESS: lucr Q �/ (sta ,county,tow <br /> cs�+. 76 I I'P Piri S 5-35 3`9 ❑Sanitary its <br /> ? ' SUBDIVISION BLOCK/LOT (publi rivate) <br /> PROPOSED PROJECT INFORMATION r AFF REVIEW <br /> PROJECT DESCRIPTION: . <br /> STD A h 6-,E 5 ))-i;: � ,(© � / • /'oning District <br /> . [This project is a new building or structure. L• Permitted -? <br /> This project is an addition Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: C3 Rural -n'`j - <br /> EWER EPTIC A (new :4,a <br /> HEIGHT IN FEET: NUMBER OF STORIEl: (No including basement) <br /> ❑ we,. i jA 41.r:In <br /> AREA TO NEAREST SQUARE FOOT: <br /> shovel: (attachme <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ Erosion COtttrol <br /> BASEMENT 1ST FLOOR: <br /> TOTAL SQUARE FOOTAGE: 4, (slopes,di t . r <br /> 2ND FLOOR: 3RD FLOOR: }I� <br /> \J ❑ Review Location Survey \ 0 <br /> ESTIMATED CONSTRUCTION COST: _ ♦ ♦ ♦ ♦ . and available option* I <br /> (Please round to nearest dollar) $ i+0 0 0 d v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes El o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es ( o <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) Dies E4o DDon't know <br /> 7. Is this to correct a violation? DYes 1:1211qo <br /> (?11 COAPPLICATION MUST BE SIGNED <br /> )( 11 (Continue on Back) —► —► —► <br /> 545-112(4/08) '✓ <br />