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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> -- -T u C EE L- 1 j Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 7 L(``f Cxzz65 C2 Q-Y t Cc-L-E variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRE S <br /> NA ( • "flO• t )88) V.g�1 �'t I C11 <br /> Ia�2f. '1c'- " Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> TI53'PARR( 0_,LE-AQ: Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS 5, • of well/septic <br /> lam P�<< <br /> (City,State,Zip) (City, tate,Zip) n Setbacks <br /> ll F.)rov■& t LA) 345- <br /> PHONE PHONE n Site Plan approval from <br /> t • 76 — 5C, I/ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usi) I Elevation of property <br /> 1 PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> NUMBER 062 0Gos--i<{-9�5a•8 12-- I 3 , frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 420 to Ilf 1•(°S PeTSw1A:,,A a0�11/<%a I/� Driveway permits <br /> ADDRESS (state, county,town) <br /> "l`fy C126 55 UrITQY C t/2'-t- W t- 1 f,? q- <br /> CSM LOT SUBDIVISION BLOCK/LOT n Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 12••4PRt0. -rM.•v6- LA;(TV' 504 0L 47pp,TZo.,J ,..40pE Li Zoning District <br /> nThis project is a new building or structure. I t " CI Permitted Use? <br /> gi,This project is an addition/alteration to an existing building or structure. / 61/ <br /> SANITARY SERVICE: PERMIT NUMBER ❑ Rural Address <br /> EWER EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> iy I I ❑ Wetland/Floodplain/ <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: <br /> ❑ ErosionControl permit <br /> l S'T'-Z-I'- LI Q 5 cti j TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: OS <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) --0. —0. -0. -0. $ I Z t 3 5C) . -- and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? JYes LiNo I Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes No I Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes flNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes `•,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) f Yes jNo Don't know <br /> 7. Is this to correct a violation? T Yes JNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 -# —► <br /> 545112(4108) <br />