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yr St-1-7—. <br /> SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVI E <br /> OWNER NAME", /� <br /> i Bea) L t 0 vG-I ass oning Status;CUP; 1 /'I <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ` Deed Restriction; CS <br /> O75' fi+[`n�gf ti � � (3(�� l� 7 575 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL AD6RESS <br /> MI I 3 20''07 [Site Plan drawn to scale 2., <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / CONTRA TOR NAME / C-01^10 . <br /> Co') 7 e-a/ G j 4'ry 1914, ErSite Plan including location 3 <br /> AGENT ADDRESS CONTRACTOR All5DRESS of well/septic <br /> Pr0,019C q3t9z2--d f.t9, 60( R )0220 <br /> (City,State,Zip) ( ity,State,Zip) 1[j Setbacks <br /> ,yr10 to a W1S 5)51, �/'L�'0 V1 at W/5 5359, v PHOI / PHONE - Site Plan approval fr 77c a- 032.C �(`•, c� 70 0 applicable township. f <br /> E-MAIL S E-MAIL ADDRESS <br /> ['Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: p p rty <br /> ❑PARCEL 2/"oq..p)'t' frontage drawn to scale. 1 <br /> MBER ®� �a.� ��� /�TOWNSHIP: SECTION: <br /> Y`",i6-6'Ft `1# '/d: hi 14/` %a'/a: m f Driveway permits <br /> ADDRESS: (state,county,town) <br /> 075 tinedn l O " Wi5 x'3 -75 <br /> CSM: �^ LOT SUBDIVISION / BLOCK/LOT Sanitary permits 9 <br /> �/ (public,private) 9 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT ESCRIPTION: <br /> CIS _ e__ t1//44-)--etc -e---- ❑ Zoning District <br /> . <br /> This project/is a new building or structure. LI Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: // ❑ Rural Address <br /> J)EWER EPTIC r 1 3` �(� .OO/cr (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> { <br /> i 1 - t n,e- ❑ 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 /> BASEMENT 1ST FLOOR: ❑ Erosion ontrol permit <br /> M P /! S 44 J- + TOTAL SQUARE FOOTAGE: j (slopes, isturbance, <br /> / J 'i filling/acc ss) <br /> 2ND FLOOR: 3RD FLOG : .. t IQ <br /> Pr tJ 2` 0 0 Q 0- ❑ Review Lo ion Survey <br /> ESTIMATED CONSTRUCTION COST: /' and available o tions. <br /> (Please round to nearest dollar) ♦ ♦ ♦ --► ♦ ♦ ) III p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Peso ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeslo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ 'es o <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# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> " 7. Is this to correct a violation? ❑Yes o <br /> ("� APPLICATION MUST BE SIGNED <br /> ""1 1 \,C\ L` N � Continue on Back)545112(48) ���JJJ ` ` h <br />