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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ,., <br /> Gce, Jd - `k c- fr,'v 72 . ❑Zoning Status; CUP; <br /> OWNER ADDRESS Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 01-f s�^'';.�o l Ll' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> .-S'7s-YyG5 5esr^y13»--.72- � 6/►3/L./ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> SA.,''7 '---'i K CS �.rc Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> PoI3ox/7c`j <br /> (City,State,Zip) (Cik State,Zip) Setbacks <br /> PHONE PHONE„ Site Plan approval from <br /> ( c > - 1r- SZO q I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Jess/S-Vc., AP Floor plans to scale <br /> lfo c, <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ' Elevation of property <br /> PARENT PARCEL NUMBER: �/ c�j CURRENaZONING: ACREAGE: P p rty <br /> El P PARCEL <br /> ER o !o_!-'3GJ - //7U-c t^ - I 0. yU9 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> UY/;t! y, 3,kj '/e: IRA; Driveway permits <br /> (state,county,town) <br /> ADDRESS: �/ `` <br /> 77 d in e,4-dcU S; c�e_ L,., ❑Sanitary permits f/ g <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> FF i�r�cVia// �- <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> NLL., C+vivS %-v ex S ,...,r i/�/=r;.-v � ❑ Zoning District <br /> . X[This 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 /> �C 6EWER FIEPTIC /V (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ' ,1f-'7 1 ❑ 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 1 ST FL R: I—, ErosionControl permit <br /> s/31 33 7' 4 TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 557 D - ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ --► ♦ iJ and available options. <br /> (Please round to nearest dollar) t1 Dc 0 /� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des NINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Des n o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Res I o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies ❑No NOTSL,-mom <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 6,4.76• ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -► -i <br /> 545-112(4/09) <br />