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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 /> R0. \ arNca MQ1Qc-e L.,,Chyti-ci.L..SEr. I I Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> s5 OcLv ■• wn \h�tx\ l,vn�;'IL u;_-_)1 LID Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL DDRESS • <br /> ..• IS".1 - 16i in it) 1.1 1/4,1C-}")-- \arteQ L-1 Cut{ 0 Site Plan drawn to scale <br /> AGENT INFORMATION• . '_ CONTRACTOR INFORMATION", s„_.; and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> l"36. Oa& 3-.)v', k'ir` []Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE []Site Plan approval from <br /> - applicable township. <br /> E-MAILADDRESS E-MAILADDRESS • <br /> El Floor plans to scale <br /> PROPERTY/LOCATION f INFORMATION htt iIlaccessdane Co da ne w,usI) '' 'F <br /> '/'mss- .-+:Y �t�._a5 <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: . ❑Elevation of property <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER QSit-311-$SOI —c 1�AAa- 11} <br /> TOWNSHIP: SECTION: <br /> i,f\jf;,r 1_ /: 1//4. M Driveway permits <br /> ADDRESS: C�� v (state, county,town) <br /> CSM:aq(+ � U4 LOT 7\ Q , Si sub `s o , W\ 5BLOCK/LOT <br /> ❑Sanitary permits <br /> 91 Z Z (public,private) <br /> PROPOSED PROJECT INFORMATION - STAFF REVIEW `{ <br /> PROJECT DESCRIPTION: it kx'x r <br /> 30l x - O �� �\ Zoning Dls nct r " =` <br /> >Xu f r: <br /> This project is a new building or structure. eke 7 �r sue, ,: <br /> �] Perinitted Use?,� <br /> ❑This project is an addition/alteration to an existing building or structure. �9 <f 1 x" <br /> SANITARY SERVICE: PERMIT NUMBER: 'EJ RUralAddre"ss r- r <br /> EWER \r�4 EPTIC E(new/e`asting) <br /> HEIGHT IN FEET 7 /NUMBER OF STORIES: (Not including basement) ' i , -K <br /> ❑ Wetland/Floodplam/ " <br /> ARC• Ti EAREST SQUARE FOOT: <br /> Shoff eland {attachment) <br /> •(Outside dimensions including unfinis d area attached garages and above grade decks or porches) uP - �. � r <br /> BASEMENT: 1' FL••R: 0 EroslonControi petmlt' <br /> J 4, TOTAL SQUARE FOOTAGE: l �,�slop_es,dls'turbance <br /> 2ND FLOOR 3RD FLOOR 2 SC s s filli.V cce s} <br /> V✓ c r kv <br /> fl Review Locafion Survey <br /> ESTIMATED CONSTRUCTION COST: and avallatii optio g� <br /> (Please round to nearest dollar) '♦ -► . "'10. "0. ♦ $ 013 co(). <br /> � .. taw. .t•tf� ..cG'.•?.x .M..... <br /> ' 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? []Yes .jNo []Don't know <br /> 2. Is there a wetland or floodplain on or near the property? []Yes ..2clo []Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ' es []No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - Eti es []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 -' lo []Don't know <br /> 7. Is this to correct a violation? QYes `10 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/D8) (Continue on Back) —I. --1.—► <br /> ( ) <br />