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*( f3e V 1,57 t `. <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUS OMER TO PROVIDE <br /> OWNERANE ^� <br /> �'7/Cf e/t1 CJ C-it/Le S SO s A e,./ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) g <br /> l/ T 2 Deed Restriction;CSM <br /> /51 , Ma�Ai (S / C✓osS hifu-s 535a Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .i. - -O I, , ` , , 3S-, 5-y5 K ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS offwwell/septic <br /> (City,State,Zip) (City,State,Zip) Ca Setbacks <br /> PHONE PHONE 'ite Plan approval from <br /> appli le township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wrLus/) <br /> PARENT PARCEL NUMBER: CURB TZOfNING: ACREAGE: 9/ evation of property <br /> 0 PARCEL NUMBER 0 g/f_293-3503-0 - / - <br /> frontage drawn to scale. <br /> TOWNSHIP: oC s <br /> SECTION: � ,►1 rivewa <br /> SA-A) Pv c , V , e a 9 1/4: s iv 1/41/4: i y permits <br /> ADDRESS: I ��� (state,county,town) <br /> -FCc•1v/Yt•- Rd o ..anitary permits <br /> CSM: LOT — SUBDIVISION BLOCK/LOT l (public,private) <br /> r <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJlECT DESC�MPTION: <br /> 2" Li- c��e d ��J• • Y( >'° ing District <br /> ❑This project is a new building or str�e. `, <br /> Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Add - s <br /> ❑SEWER fa SEPTIC (new/ <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 — / I ettanc Flaodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: /. 1Un�' "" aim <br /> ,� TOTAL SQUARE FOOTAGE: 4 (.slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/ac ess) <br /> al Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and available o <br /> (Please round to nearest dollar) $ /i 000, O d options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ®Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? J Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ®Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 902 y9 ) (leave blank if none) <br /> . Is a location survey required? (see re rse) ❑Yes allo ❑Don't know <br /> 7. Is this to correct a violation? tt ; .S•e j.[. ,4 <br /> cti T tv-17 aYes LINO <br /> S ctwet,ye 0.f. a.l ( Z der ca T S <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) ■ -+ -r <br />