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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME le 4,)c�ST1 ti--,s o zw■K CAAYa•X2l 'tom A `l.,.c?+—� Zoning Status;CUP; —3 <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 9'337 W id n-620--r t. 1441,0804) W f Deed Restriction;CSM d / Z- <br /> S3S�� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> looff3305''7`DZ -,- 332'157£57 uyC'.1*l 3 0 2.,...4; 1h4-0 0.cam Ei Site Plan drawn toscale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions?Z e 0 <br /> AGENT NAME CONTRACTOR NAME <br /> ( }1M�b�e� , ,t,es ciatl, R-ivc� ( rte; -i- ,j.�.0intts ElSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> I ?td V2 C n.2.tAC 190 I Tyg-o C Y 6 3'/30 2 5ry <br /> (City,State,Zi ) (City,State,Zip) Setbacks <br /> YAP Zi � (J•41 S-S77--- vv(sr.1-1-mas (am) s3S1 Z A <br /> PHONE PHONE Site Plan approval from i'v A_ <br /> (¢O`c5 • s-13 • 7 C.o Si toots • G-13. 7( ,% 7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ,L. 104 Ftte.(AlA5i€C 04/9-C• • cosy._ J het, Got e& 1C .Cow Floor plans to scale iii <br /> ttrvl C�1w• <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT P.RCELL)MBEZ CUV ENT ZONING: ACREAGE: <br /> ,� Elevation of property 4 <br /> El PARCEL I/2OJ,-kv u i, <br /> NUMBER i <br /> fi1 2 76 frontage drawn to scale <br /> TOWNSHIP: SECTION: Zg r7N R-7a r <br /> G 65S FLA) 1.1 e Ya: S� Yoh: i Dri <br /> cg-65s per <br /> (state,county town) <br /> ADDRESS: <br /> �' ? � c <br /> 13IvaValle e, 41 <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ( ubl C ry • its <br /> / /41S Z l (P <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: , <br /> 74atiz l7.16. /--6Akr►2i 61 404,-&5 ;Zoning District �t+T q� <br /> . This project is a new building or structure. �'l Perm' e Uir /// <br /> This project is an addition/alteration to an existing building or structure. / ,` ew/, <br /> SANITARY SERVICE: PERM UMBER: v ✓v! rt Address 19 r+v ©0 <br /> EWER EPTIC 1 2 O1! — t 0 Z / e xisting) Z. 7 A l <br /> HEIGHT IN FEET: ) NUMBER OF STORIES: (Not including basement) e,F' ?' -71,1 d <br /> i A _ d/Floodp m , <br /> Shorelan. (attachment) Cj <br /> • AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or por • - ErosionControl permit <br /> BASEMENT: 1ST FLOOR: L, 0b <br /> //(Q 1 ./?23 ,o TOTAL SQUARE FOOTAGE: (slopes,disturbance, �4 <br /> 2ND FLOOR: 3RD FLOOR: l U - filling/access) <br /> Z 9 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. #�� <br /> (Please round to nearest dollar) Ce00r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies [ lo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes alo oDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes Olo <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) QYes Do ['Don't know <br /> 7. Is this to correct a violation? [Yes po <br /> 4-' ,, ye, . APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► <br /> sasttz(4/061- <br />