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ZONING PERMIT APPLICATION www.countyofdane.com <br />SUPPLEMENT to Web -App # <br />PROPERTYINFORMATIONCUSTOMER <br />OWNER NAME <br />TO PROVIDE <br />-S,M J <br />❑ No <br />�' `ea <br />Zoning Status; CUP; <br />Deed Restriction; CSM <br />) <br />❑ Site Plan drawn to scale <br />OWNER ADDRESS (Number, treat, City, State, zip) _ <br />1,57D c-�E� d l�- d r -f-a n c.� j <br />HOME PHONE CELL PHONE <br />L00,5 /- 00 9J <br />E- AILAdDRESS <br />b I ►" ack to of C� <br />INFORMATIONAGENT <br />-'Q No <br />and includes dimensions <br />AGENT NAME <br />CONTRA TOR NAME <br />`-) LF <br />&Site <br />E <br />Plan including location <br />of well/septic <br />Z/ <br />Setbacks / <br />AGENT ADDRESS <br />CONTRACTOR ADDRESS <br />-k",— <br />(City, State, zip) <br />(City, state, zip) <br />,f <br />Site Plan approval from <br />applicable applicable township. <br />1 / <br />0 Floor plans to scale Lit <br />Elevation of property <br />PHONE <br />PHONE <br />&,og L41 <br />E-MAILADDRESS <br />E-MAILAUDRES <br />kj Ir' M Cr, ► <br />.. (http://acc:essdane.co.dane.wl.us!) <br />PARCFL NUMB CURREN ZONING: ACFSEAGE: <br />/� <br />❑ PARCEL /%S ��� �Y��� q . 2 ; <br />frontage drawn to scale. <br />NUMBER (.� vvv <br />Driveway permits <br />TOWNSHIP- <br />�Q <br />SECTI <br />1/41/4: <br />J b/a: <br />(state, county, town) <br />ADDRESS: <br />1570 CI A Ed q er-ton 1,03S3 <br />arypermits <br />SanitSanitC, <br />CSM: LOT SUBDIVISION BLOCK/LOT <br />private) <br />PROPOSED PROJECT INFORMATIONS7AfF <br />RiEV� <br />PROJECT DESCRIPTION: D <br />d t o LcSCI sT /VCs ©(,1 F D U S L c(I �) <br />�� } <br />District C, it <br />0 <br />❑ Permitted Use?' <br />❑ This project is a new building or structure. <br />.� This project is an addition/alteration to an existing building or structure. <br />- <br />Rural A <br />SANITARY SERVICE: <br />PERMIT NUMBER: <br />❑ SEWER .SEPTIC <br />©V1l@t(antllFloodEairl/ <br />HEIGHT IN FEET: <br />NUMBER OF STORIES: (Not including basement) <br />1 5 7 <br />Shorelland fat chment) <br />AREA TO NEAREST SQUAME FOOT: <br />(Outside dimensions including unfinished area, attached garlages and above grade decks or porches) <br />❑ Erosion,'s�-1 <br />(S ow' distu"I ' r <br />BASEMENT: <br />1ST FLOOR: <br />1 t % % <br />/ 1 <br />l TOTAL SQUARE FOOTAGE: l <br />A <br />2ND FLOOR: <br />3RD FLOOR., <br />/� <br />/ // 7 <br />L./J <br />N <br />C� Review Location Survey <br />and available options <br />ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -► ♦ ♦ <br />(Please round to nearest dollar) <br />Q� 1� <br />�p / <br />1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ........... <br />2. Is there a wetland or floodplain on or near the property? ............................................ <br />3. Have you talked with the township about your project and are they in agreement? .... <br />4. Has there been a zoning permit issued for this property in the past 5 years? ..�IE.S.. <br />5. Is this project associated with a rezone/CUP/variance (petition/appeal # ) <br />6. Is a location survey required? (see reverse) ......... ............................. ............... <br />7. Is this to correct a violation? .............................................................. ..... <br />545-112 t4/0el <br />❑ Yes <br />81 No ❑ Don't know <br />❑ Yes <br />allo ❑ Don't know <br />0 Yes <br />❑ No <br />Yes <br />LINO <br />(leave blank if none) <br />❑ Yes <br />"-6 No ❑ Don't know <br />❑ Yes <br />-'Q No <br />APPLICATION MUST BE SIGNED <br />(Continue on Back) <br />r) <br />01 <br />t <br />