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1n ( a i � <br /> ZONING PERMIT APPLICATION www.countyofdane.co SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ��// OWNER NAME <br /> IC ttn4'SCc It G.,, .e_!' ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zi Deed Restriction;CSM <br /> If 6 ( w /►1 iQ J A f S/t q �( L(/�t-- 53 557 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60 y 2.ao— 1 i 5— bit/c ck eu -'L <br /> 1 ctt J - w►6 I, Co ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTO'NA iE ' <br /> AA A SI a Plan including location <br /> AGENT ADDRESS 111111•1111 CONT'. •'ADDR �' of well/septic <br /> _; —�--� Setbacks <br /> (City,State,Zip) , i , . -r ❑ <br /> po, <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 63`/d7iA-3241--T5cf_7 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ill 4 i n 4 3:. 1/4: N 1/41/4: 5 E El permits <br /> X11 (state,county,town) <br /> ADDRESS: 41 dd <br /> I I b I W 414 ilh4, m atiA,t,(( "- <br /> 5-3 5/ ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ` <br /> /1)0`)C 60'y 4/I wtu.G'' <br /> '►+h Sit.4 ❑ Zoning District <br /> . ❑This 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: ❑ Rural Address <br /> EWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Li Wetland/F000dplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionControl permit <br /> BASEMENT 1ST FLOOR: disturbance, <br /> 1 TOTAL SQUARE FOOTAGE: 1 (slopes, <br /> filling/access) <br /> 2ND FLOOR. 3RD FLOOR: <br /> 7i A0 `) <br /> Li Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ , I V and available options. <br /> -P -► <br /> (Please round to nearest dollar) ' 3`7/d O M ' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes QNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes /No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 0Pes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes QNo <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) Ekes allo ❑Don't know <br /> 7. Is this to correct a violation? Dies QNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -i <br /> 545-112 14;08) <br />