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4 • I. <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �! l <br /> D cqi I i t STI , 1 d-kcSo N ❑Zoning Status;CUP; <br /> OWNER ADDRE S (Number,Street,City,State Zip)f '� 1-� Deed Restriction; CSM <br /> - q 2-L/ � 6-4(-C 0 >�a 11) S�, V e ron r^- I�J-�/ S35%� variance(# ) <br /> OME PHONE CELL P •NE E-MAIL ADDRESS <br /> 1065))t 2o3-5( i of b 0`149/(0 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRRAATOR NAM 5, ) <br /> j�a ve i�GtS U.5 1 <br /> 5en CUKNE /'/0 fill i S INC. ❑Site Plan including location <br /> AGENT ADDRESS _ COPu RACT R ADDRESS of well/septic <br /> /0 Sox Lip //0 D?< L/5-4/0 Pad/son 1 <br /> (City,State,Zip) (City,State,Zip) D� �� ���t'���y� Setbacks <br /> 1 aciSGY) �l 5370 i° 604 ❑Site Plan approval from <br /> P ° ��) /O_ Cr J S- PCo ) S3 - ZDr* applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑Elevation of property <br /> PARENT PARCEELN MBER: CURRENT ZONING: ACREAGE: <br /> 1:1 NUMBER b 3 v4 N <br /> 03-0 /6/Z-• //1 5-D r - a /, 573 frontage drawn to scale. <br /> TOWNSHIP: ,�y� SECTIO • <br /> T D Gurl OF / ' 'icj l e-I-ar. f '/4: IRA: ❑Driveway permits <br /> ADDRESS: G (state,county,town) <br /> 3 I S5 CAM bou C1-/ ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 6cnn' S Po��1+ (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIP <br /> TIO ie(,J Cons-t-u c7t/o) ❑ Zoning District <br /> . ge his 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:�7 ❑ Rural Address <br /> EWER EPTIC (j 1 - 0 d Z C)5 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 31-/ -Fl. 2 S+-or 1'eS LI Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT <br /> (Outside dimensiinsj chid g^Enfinished area attached garages and above grade decks or porches) <br /> BASEMENT: (D 1ST FLOOR: ,/oQ / ❑ ErosionControl permit <br /> "7 CJ + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> ' S�j•� � Sc1� filling/access) <br /> 2ND 1 FLOOR:3 i� s •f+ 3RD FLOOR: el O` %` t' `/+ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: , /� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ Cp!aI pag <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ONo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ❑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? Dyes ❑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 ❑No ['Don't know <br /> 7. Is this to correct a violation? [Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ —► —► <br /> 545-112(4/08) <br />