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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 /> Q 14 v kOK <- 5gje - 5e /o uqh p Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) //11�,, ��S Deed Restriction; CSM <br /> G2 9 a) C*m p I-OMA- ) e6, v(C,�4l ft-llA Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> G og 51b- ,as d44 0 ceexiikiNc.co/K ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> k4 f�-E� �N67, Lc.� 4 >� -y A1c7 I �� ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7036 / I lei e-54-to (Dn heirs -- 140 <br /> (C'(,State,Zip) (City State,Zip) ❑Setbacks <br /> 02 L'bOA/ w Z 53 s'1 OeC60,,f W 5--S5-71 1--- <br /> PHONE PHONE ❑Site Plan approval from <br /> /..Q <br /> k o 8 v2 7 z-D 6t, jt D y id applicable township. <br /> E-MAIL ADDRESS E-MAILAD.- SS <br /> 4 tft Gd/1e . wit.. ,, 40 edAe , co,k. ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL ( 4 2,e,15 +c- frontage drawn to scale. <br /> NUMBER O$O°t-O$l-Q,p$+�-O g7}'4_ <br /> TOWNSHIP: SECTION: <br /> O/r G 66,,,,J Y4: IRA: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS: v <br /> 5611 C Ty� r /key ❑Sanitary permits <br /> C/ 3 M: �� LO SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: (� <br /> / 4/ 5 i Al' -F4--AC■/c( h O�1 CI Zoning District <br /> . This project is a Al/ 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 [EPTIC /3-a b/!O - 00 3 yz— (new/existing) <br /> HEIGHT IN FEET: t NUMBER OF STORIES: (Not including basement) <br /> a a / ❑ 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: ❑ ErosionControl permit <br /> .6 .Sg 3 c96 + TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: (�/. ) J� filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --► ♦ ♦ -�► ♦ ♦ ?g 8 ,� and available options. <br /> (Please round to nearest dollar) J / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? les 'lo JDon't know <br /> 2. Is there a wetland or floodplain on or near the property? E Tres alo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es [alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eyes faro <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 o ['Don't know <br /> 7. Is this to correct a violation? [Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545112(4/08) <br />