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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 /> kRIS L_ A/2.. <br /> AZoning f Status; CUP; /ONE DRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 500 Co/i ri/7' hiev1' , 1 /1)/¢0/5044 /// 6:i7/9 Variance # <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS WSite ( )) if I <br /> g33-: Sz ' 2-�it/Z®/���77LS•can Plan drawn to scale r -i'U <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 2i9 Ye 4 F4JZ jSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /�D o �p vAi7 f' /7401 ryt <br /> (City,State,Zip) (City,State,Zip) Setbacks '� t/Z`� C/ <br /> PHONE PHONE _ Site Plan approval from A <br /> bo F - S 33 -8�'So applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> it Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: El Elevation of property <br /> ❑ NUMBER 49 70801719 2 704' /9 1 7, , frontage drawn to scale. f <br /> TOWNSHIP: SECTION: <br /> wow y d f rn i j)L(7o p2 7-7-.5 '/a: 5.1 1/41/4: S Driveway permits Ulv/g <br /> ADDRESS: (state,county,town) <br /> © CO 0417? m 'F Al h1/ )/ '4/ /Gv/ 3:-.?7/e7 (/:1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits N/t11... <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ggiZoning District A <br /> . 'This project is a new building or structure. Permitted Use? '....e cki <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1'RuralA.. - s <br /> ❑SEWER ❑SEPTIC (new I <br /> HEIGHT IN FEET: NUMBER OF/STORIES: (Not including basement) ,�/ <br /> /02 _ eWetland/Floodplain/ ,,, <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 4 ErosionControl p <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbs <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 998 Review Location Survey Ai/4___. <br /> ESTIMATED CONSTRUCTION COST: -► -► -► -► and available options. / <br /> (Please round to nearest dollar) $ /011 Q a <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes /afNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Li Yes ICJ No Li Don'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? ❑Yes No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank. none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? Li Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ■ -+ <br /> 545-112(4/08) <br />