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ZONING PERMIT APPLICATION www.countyofdane.com 13=3:C=M1 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME . <br /> _ILVAL ...._. El Zoning Status;CUP; <br /> OWN Fi ADDRESS ;Nt.mber.&reef,Oty;State Zip) Deed Restriction;CSM <br /> /6 1± 7-.: C fy......Sd 7A" P, .13)1Qc..lie L-4' ,i5141/ ..._ ii.-Cii I %,..572:3..:)-.7..:41-.. Variance(# ) <br /> HOME P.-IONE CELL PHONE E-MAIL ADDRESS <br /> -.3 ".,0 -Li-:2 2-0.6-.Y i,rdst? iette..nrnonck&, (1J`K,c.,' tort, Lj r--1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -5 e li fl site Plan including location <br /> AGENT ADDRESS -CONTRACTOR ADDRESS of well/septic <br /> ,s_4?,in r <br /> (City.State.Zip) (City,State.Zip) Cli Setbacks <br /> PHONE PHONE .-----' ED Site Plan approval from <br /> - applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ID Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danemLusl) <br /> PARENT PARCEL NUMBER: !CURRENT ZONING: ACREAGE: El Elevation of property <br /> 0 PARCEL ° got; ;47'1 g'Sec-s- 1 <br /> 1 37 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: 1 SECTION: <br /> F......4_ 4___ 1,274-k iA: N id 1/4.1/4:s E iy E Driveway permits <br /> ... (state,county,town) <br /> 'ADDRESS: <br /> J 0 Sanitary permits <br /> CSM LOT SHJEDIVISION ;BLOCICLOT <br /> (public,private) <br /> 1 I <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: c; 0 Zoning District <br /> -7;41 k If/1...tei cil_e_cill,-. c k 2,-tr..__1,. re,,,h/4,e,,.__itt.e,_11.LCSec".L.'d,.) 1-611,01) , <br /> . DThis project is a new building or structure. LI Permitted Use? <br /> DitThis project is an addition/alteration to an existing building or structure. <br /> -,-- <br /> SAN!i ARY SERVICE: 1 PERMIT NUMBER 0 Rural Address <br /> [ EWER ELEPTIC 1 (new/existing) <br /> HEIGHT IN FEET I NUMBER OF STORIES (Na ir:Ouding basement) <br /> / r / Li Wetland/Floodplain/ <br /> _. i ...; i 1 <br /> — Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area;attached garages and above grade decks or porches) •.--. <br /> i....i ErosionControl permit <br /> BASEMENT 1ST FLOOR: <br /> As- x ao i ` A ,x 4 TOTAL SQUARE FOOTAGE. 4, (Slopeaccesss,disturbance, <br /> x ge gP-0 ci , filling/ ) <br /> — <br /> 2ND FLOOR: 1 3RD FLOOR. ..-41 11 ;ITht <br /> _ , Li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST -4. -0. 'Th <br /> and available options. <br /> - <br /> --0. --00 '''N <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? ['Yes ao 0000 know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Do 2Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? aes OW <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes [51 ,to <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) aes Ei: o EjDon't know <br /> 7. Is this to correct a violation? Efres la o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4- -* -4 <br /> ' 2;4:081 <br /> - -- <br />