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i ,�?� D Fe. <br /> ZONING PERMIT APPLICATION www countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN NAME <br /> i <br /> QN.K- inQX V�1r, <br /> (MA4\111 ❑ Zoning Status; CUP: <br /> OWNER ADDRESS (Number.Street.City,State Zip) e <br /> co(oSO -rtaR7Ar��RA I L- VU/4 VgAigic, 1 S� Deed Variance Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE 'E-MAIL ADDRESS <br /> e9/, - ;37-ow)9 A14 4saa c(r)exIQ A • M:1 C4A2 ` <br /> TEi, c1❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State.Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE J Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT '//PARCEL NUMBER: / CURRENT ZONING: ACREAGE: CI Elevation of property <br /> j PARCEL <br /> NUMBER V/. 9//1-303..4Q 0 A- I d.'7 3/ frontage drawn to scale. <br /> TOWNSHIP:* SECTION: <br /> e121ST(?,.. 30 '/,:5� 1/1/: 5 ❑ Driveway permits <br /> ADDRESS: p (state,county,town) <br /> dy6.S'D " r4t TA 3 -rep/4 `ep/G SL{ ( ,1 Ire ' S-33r9-6 ❑ Sanitary permits <br /> CSM: LOT I SUBDIVISION BLOCK/LOT (public,private) <br /> S. 1 tRet:$ KS E T,a 1. <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> A f)Vt TOi:3 eARPOE ❑ Zoning District <br /> Li This project is a new building or structure. ❑ Permitted Use? <br /> A This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER 11 SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2C2> Ud ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FO T: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT •1ST FLOOR' 1 ❑ ErosionControl permit <br /> �Q� 1 j, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> (,,,,►► �1/B� filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> r- I ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: - $ u o© and available options. <br /> —I. —I.(Please round to nearest dollar) 0 0-6 <br /> / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes L No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑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 i 1 No <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) J Yes J No J Don't know <br /> 7. Is this to correct a violation? J Yes keJ No <br /> 36 APPLICATION MUST BE SIGNED <br /> Y+�^ (Continue on Back) -+ —► <br /> 545-112(4108) <br /> g6, 0° <br />