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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER A E <br /> /( --615 -a-Zonin Status;CUP; <br /> OWN ADDRESS ( mber,Street,City,State,Zip) g <br /> Deed Restriction;CSM <br /> Variance(# Z) ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> i Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> QUI/n/7/ /I.iff7— (10.1 7- .Z-4.,(_ Cam' IZ/7y l ] ( s,j y�,.,C.-__I-0"Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /7 Q et x 1 Z /4. O. , o r /Z <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE i PHONE / ,a-Site Plan approval from <br /> 79 0- 77-7Y Icy 0,-3-77y applicable township. <br /> E-MAIL ADDRESS E-MAIL A DRESS <br /> if 'f �� F ,�,,,� Jloor plans to scale <br /> our Li i-E- we Cthoo - (C)tat <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ZONING: AC SAGE: =r cievation of property <br /> ❑ PARCEL / f� �/ frontage drawn to scale. <br /> NUMBER 6S:6 V`30477/3'0,007-U /} / <br /> TOWNSHIP: SE TION <br /> S'f> /A/t1y /F? S 1/a: J I,4-1/4: A/ rive,count permits <br /> ADDRESS: (state,county,town) <br /> i3 16 b /40 4/r,e21 C1 gc i r unitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> 2 C6 ,« , LT .. <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> pi 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 /> ❑SEWER I 'SEPTIC S— Z 7 7 (new/existing) <br /> HEIGHT IN FEET: / NUMBER OF ST9 RIES: (Not including basement) <br /> &/'„ ( ❑ Wetlancolilain/ <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: r-1 1 roStpnC'#tltrpttt <br /> z/.7 � } (J�j� 4, TOTAL SQUARE FOOTAGE: (slopes, ess <br /> 3l tilling/acce ss) <br /> 2ND FLOOR: 3RD FLOOR: <br /> , ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) $ /�O/ (�U O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes callo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 51No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? SYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes A 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 Cg No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 48 No <br /> 4' APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -► <br /> 545-112(4/08) <br /> )3c ° 12 <br /> ( ) ♦ <br />