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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME Ph t ' 'e ke r� erz <br /> _ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number, /tre�et,City,State,Zip) Deed Restriction; CSM <br /> 31 I a lu u A-1 I�..Q, < uk , Lo ,5-135---g___ <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> _ate3-3373 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> �C e ;!04-et.ie it 44K6-x°V PALS 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Se/8 Aa <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> /1/P D16,6,4 co/ 5-37/ 8 <br /> PHONE PHONE ❑Site Plan approval from <br /> COOS—2Z2—/7,30 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> dvOt-oUe.e-r u.,et(p upc s,eowc ❑ 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 /> C PARCEL BER 0615/0 90 7-40Z-%7/~i P. lF-3 Sd 4 frontage drawn to scale. <br /> TOWNSHIP: SECTI ( <br /> -h(,0ti o-f (pVC6 0�-`� © IA: '/4'/4: ❑ Driveway permits <br /> ADDRESS: n n (state,county,town) <br /> 06 3 ` I1O r tL i2 2. ❑ Sanitary permits <br /> CSM: 2 ( LOT 2 SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> /8'X 3l' l rt-)g2owucC SCOW',141„uj form ❑ Zoning District <br /> . INZhis 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: ❑ Rural Address <br /> FIEWER EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 0 ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> B sEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> .---- 4 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: 17,4g filling/access) <br /> 6 ESTIMATED CONSTRUCTION COST: oo ❑ Review Location Survey <br /> .S' Wu' and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ / ' �' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No 1:()on't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ❑No ii on't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des ❑No dieor k A7--1(4-) <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 No ❑Don't know <br /> 7. Is this to correct a violation? Des 21No <br /> g 6 g APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -► - <br /> 545-112(4,08) <br />