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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER <br /> ( LO <br /> ' ` A N Lv� ❑ Zoning Status; CUP; <br /> OWNER ADDRESS ( r,Street,City,State, Deed Restriction; CSM'KAJ-3 t---1 g � 1-- Pt Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> - ,a 0 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ACTeR NAME( \V <br /> Sl U u,-�L , ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACT R DDRES of well/septic <br /> Z2L,- ? R� <br /> (City,State,Zip) (Crate,z , _ ❑ Setbacks <br /> PHONE PH' ONE�r A�i� �- ❑ Site Plan app roval from <br /> Lbg -- L1-44 :1 \( 3 applicable township. <br /> E-MAIL ADDRESS -„•IL ADORES <br /> - Q-1114 ..❑ Flgor plans to scale <br /> `'oa. . . aR_ 41t6.2_46. E_�-- <br /> PROPERTY/LOCATION INFORMATION (http://accessc'ane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> PARCEL 7�j/ / frontage drawn to scale. <br /> NUMBER �L ��j�� ��('� —6 <br /> T SHIP: SECTION: <br /> L)y,- 3 -Co 1/4: 13 1/41/4:0 ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 1163 L)uo( J ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 3 ' 1 <br /> 1A <br /> k ' j— c.)t �, <br /> .iVj t.t,- ° ❑ Zoning[?:strict <br /> ❑This projt is a ew building or structure' ❑ Permitted Use? <br /> P-41 his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ❑ Wetland/FloodplaiN <br /> 55 l Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r~t <br /> BASEMENT: /' 1ST FLOO�v" <br /> 4..A ErosionControf permit <br /> / 7 �.( 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: s �{ 3RD FLOOR: / J �' <br /> /0 3 I / ❑ Review Location Surrey <br /> ESTIMATED CONSTRUCTION COST $ /��' 92 and available options. <br /> (Please round to nearest dollar) ♦ "♦ ♦ '♦ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Cl 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? UYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes gitNo <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 lallo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 4No <br /> 77 APPLICATION MUST BE SIGNED <br /> 545-112 taroat <br /> � (Continue on Back) ♦ - -0 <br /> i L <br />