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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 /> R LTA, p--0 -e- ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) r Deed Restriction; CSM <br /> 5 ci 5 7 4/ -N/Te Laity lifet- /)/t j, 5355$ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4c...-5-79-J -R;o r i4rs 2. 0 1PtlLr2O/1 ❑Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> (A L T i coAL5Tki.ie l ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 405 MomakiA -Diz, <br /> (City,State,Zip) (City,State,Zip) <br /> mi p) ' 1 . At _ ' ❑Setbacks <br /> L�t DytitA) Gu `J l► 37l <br /> PHONE lO <br /> PHONE zzl-�z_t Z o• El Site Plan approval from <br /> (p OS-235.--51,-13&// applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> • I , smeGI-c.6c9ma.tr-,Coow1 EJ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: -210 <br /> ��o 1.CURRENT ZONING: ACREAGE: p Elevation of property <br /> 0 PARCEL <br /> NUMBER 06 I1-3c4-1141(4I e --�j 1 frontage drawn to scale. <br /> 4 <br /> TOWNSHIP: SECTION: <br /> --rou346 F P`.64-5,Ap JZi gs 50 v: 5e ih : NE ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> Zg,-U-17Z4e-Y /-Al. S7271i4/tra 1,4)4 53589 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> b 40 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> -11elpto, &x,t6ii 1467 _ Cat2t W1.17 / CIA, ❑ Zoning District <br /> EIThis project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER }EPTIC (new/existing) <br /> HEIGHT IN FEET: i a NUMBER OF STORIES: (Not including basement) <br /> .31 -G Q' ,�aS 2, CI Wetland/Floodplain/ <br /> r 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: ❑ ErosionControl permit <br /> 14 0-1 2.355 + TOTAL SQUARE FOOTAGE: j (slopes,disturbance {-, <br /> filling/access) �►`'/' <br /> 2ND FLOOR: 3RD FLOOR: <br /> i UUs 474:7 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -�► $ -' and available options. <br /> (Please round to nearest dollar) $ '42'55 0Oor <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑No ['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? EYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑YesVo <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) :b es •i o ['Don't know <br /> 7. Is this to correct a violation? ❑Yes I/ o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aroe) (Continue on Back) ■ -0 -► <br />