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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> OWNER NAME <br /> Mjghf� Ogk ):qt'Nt LL.0 Io.,r,A�y Gs«.jAc, ✓Chyck/Svy;c ;ci -I ` Zoning Status;CUP; <br /> OwWNNtRAD RESS (Number,Street,City,State,Zip) <br /> �� �''7�2� �� eed Restriction; CSM <br /> _ �r l(( 1.t c I4 040c. _ , ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 1 <br /> C6 t-370- 19 1 5 sot-314'571r "ri'<.61LSL t ti 2- (I - Ili; I- cool i Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> H, N Peg)) i SPAS _ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD ESS f well/septic <br /> pc Boer 9/4 <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> )Jorilt. Hy, wt. X39 91 <br /> PHONE PHONE ❑ to Plan pproval from <br /> f;0Y - 'f•3-3P "( plica etownship. <br /> E-MAILADDRESS E-MAIL ADDIRESS <br /> e j14.441) (y W)00), c cr), loor plans tos e <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Ele atlon property <br /> ❑NUMBER ("�}PARCEL MB�1;: _ Q�CURRE�T ZONI /� ACREAGE fr tae rawn to scale. <br /> TOWNSHIP:� G v llv i.�� sECrV IQrI� 1/4: S 1 I i ,�\ ri way permits <br /> w /4/4: /v (st te,county,town) <br /> ADDRESS: <br /> C,5"y(' 4 e t '.) 1)49(-- %/1 ,c ,r-2 1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT a I ary permits <br /> (p blic, •rivate) <br /> PROPOSED PROJECT INFORMATION ST. FF REVIEW <br /> PROJECT DESCRIPTION: <br /> jny,ec�)h d z t7 X 4o ,54)91 rvim/Ili re I a o ng District <br /> . ©This project is a new building or structure. ❑ Permitted se? <br /> This project is an addition/ Iteration to an existing buildin o structure. <br /> SANITARY SERVICE: PERMIT NUM R: ❑ Rural A dress <br /> EWER EPTIC I (new/@XI <br /> HEIGHT IN FEET: NUMBER OF STORIE S. ( t including basement) <br /> ❑ Wetland/Floo lain/ <br /> Shorelan attachme <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 /> ErosionContro ermit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,dis bance, <br /> 2ND FLOOR: 3RD FLOOR: filling/acc s) <br /> goy' <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -► ♦ ♦ r� CO.D p and available options. <br /> (Please round to nearest dollar) J i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes jlo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes ITho <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 jNo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes to <br /> 545-112(4/08) APPLICATION MUST BE SIGNED <br /> I (Continue on Back) —0. —0 —1. <br />