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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME/� ,9 d /��� ,�j- / <br /> fl �/("b € 7 Le3TI 2f4/C ❑Zoning Status; CUP; <br /> OWNER AbOJF4SS ( mber,Street.City,State,Zip) Deed Restriction; CSM <br /> i", V,X 4LS9V1 "foiior,iv!s71I-f,W Variance(# ) <br /> HOME PHO E CELL PHONE E-MAIL Min ADDRESS �/ + / �►�j <br /> -1S-Ark:5 ,, , -377 Mi sieve•3/dal- "'J ` ivie'en Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NP�Mr��n S� CONTRACTOR NAME /�� <br /> cJC Ct�j iL y 0/0'16 Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> #. '4'X 4f4‘02 rc 11AP"4W/fex' 'WOO <br /> (City,State.Zip) (City.State,Zip) ❑Setbacks <br /> //— cY7 'c' -- / / o /4=9"0 w.z s'3a7g '22' <br /> PHONE PHONE ❑ Site Plan approval from <br /> tier- 6677-38.81 77-38'x / !ip-swe-- 17v1/ <br /> applicable township. <br /> E-MAIL ADDRESS r_ E-MAIL ADDRESS <br /> 5 free. .$!U 4.fien ra siaPPeriPi ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CUR ENT ZONING: ACREAGE: <br /> ❑PARCEL p �� _� c frontage drawn to scale. <br /> NUMBER 6`7 O'7 -I( 3 - $O$Z' <br /> TOWNSHIP: SECTION: t , 1 El Driveway permits <br /> C�ea5 5 PL,4//�S it 1 /: 5 k) /</: .5W (state, ay permits <br /> town) <br /> ADDRESS:1 01 5/-Av LLo_(P* ii gpf <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> - R4 I (off in /k -�r <br /> ,# L.1 Zoning District <br /> 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 /> EWER [EPTIC v P (new/existing) <br /> HEIGHT IN FEET.t �t NUMBER OF STORIES: (Not including basement) <br /> _, i J Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: I—, <br /> ErosionControl permit <br /> 3°x S� TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> p filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2'E' 7-1 J Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) —' -P. --o. —' - $ J 20c <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? ❑Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Dies ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres ❑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) Efres No ❑Don't know <br /> 7. Is this to correct a violation? Efres No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -. - -♦ <br /> 545-112(4/08) <br />