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ZONING PERMIT APPLICATION www.countyofdane.com F:2=== <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER ME `` 1...004,4---CL r I O c ID I e. .5-3s-s? 0 Zoning Status; CUP; <br /> OWNER DRESS <br /> oZ (Nuy mber,Street.Cit State,Zip) <br /> 2 (� o a MO r a I 0t_ Deed Restriction; CSM <br /> 1�- / I C W Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL AD RESS <br /> 1:- S.--T-IC- d Jo 602 il 6' • Ilia d co" ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT AME CONTRACTOR NAME I <br /> /)an Thorson i GL �l.l,I. IO ( r'1 S ❑Site Plan including location <br /> DD <br /> AGENT ADDRESS CON CTOR ADDRESS of well/septic <br /> os-(Ci tale.Zip) ity,State,Zip) ❑Setbacks <br /> UV)(40bu 3 ltd It - S392innZ.o,y nie, 0 Wr.. 535 <br /> PHO r PHONE ❑Site Plan approval from <br /> V d d - 3 Lis/ - /a 3S dog - 'MC - q y applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 8' 7 c i1 frontage drawn to scale. <br /> NUMBER <br /> O 75 /�t <br /> TOWNSHIP: n SECTION: <br /> e d '1 a N 1kij 1/4: N j ,/1/. ❑Driveway permits <br /> ADDRESS:`, a (state,county,town) <br /> g e Roced nict iia)1 (,01-. ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> 0(.1.-F bi,�i Id if), 7 fQ -rive ❑ 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 [XEPTIC (new/existing) <br /> HEIGHT IN FEET: 1 t r NUMBER OF STORIES: (Not including basement) <br /> J , ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> 1 20^ O 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 100 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q and available options. <br /> —0 -0. ♦ —0 —0 ♦ <br /> (Please round to nearest dollar) $ 1 t S e <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes N, o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies KNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes 74 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes L 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) Ekes 1No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />