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. 33 <br /> "ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ` 1)1iA4-1 ❑ Zoning Status;41, <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �'n�` is Deed Restriction, SM <br /> HOME PHONE 511 Nw roc ON ��,_Mg izort ADDRESS bru , co' 5351S, Variance(# ) <br /> *4 7.067 <br /> Git<e Plan ditivn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and' cludes dimensions <br /> AGENT NAMED CONTRACTOR NAME <br /> 5`�A� t�L-k4 - �..P . %lwlK� C41Clq• Site Plan including location <br /> AGENT RE CONTRACTOR ADDRESS of well/septic <br /> (31¢ F,Ntlt, STS Co-yvi X1 l <br /> (City,State,Zip) (City,State,Zip) La JeiDBCkS <br /> _. — F ico 4 Ll 53-113 o r <br /> PHONE PHONE r� 1 ��'te Plan appro4al from <br /> (DO,-251- 228° applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> (.0-1-it ..'.E514.11 1 Ilan,f aM cWoor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane,co.dane.wi-usl) <br /> PARENT PARCE UMBER: CURRENT ZONING: ACREAGE: kie‘vation of property <br /> ❑ NUMBER dfv Ott`Z22-11214) A•I EX, 62, frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ill r•IA 22 %: 14 k 1/41/4:�W Driveway permits <br /> ADD SS: <br /> 141 <br /> FALL county,town) <br /> CSM: t40 L4 6 WOG F484 SUBDIVISION BLOCK/LOT Sanitary permits <br /> public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 41-1 ciOiliit SW E Zoning District <br /> . 34,This project is a new building or structure. Ur ermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ural Address <br /> • EWER ?A* PTIC (new/existing) <br /> HEIGHT I • ET t NUMBER OF STORIES: (Not including basement) <br /> I ❑ Wetland/Floodplain/ 4 <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (0 ide dimensions'•..i ding unfinished area,attached gara above grade decks or porches) <br /> BAS 1ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> 121150 filling/access) <br /> 2ND FLOOR: 3RD FLOOR: M c <br /> SO $ I ' I eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► /�/� and available options. <br /> (Please round to nearest dollar) $ ,116 W9,d0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes "No (3Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes „lill•lo rpon't know <br /> 3. Have you talked with the township about your project and are they in agreement? �s ❑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 bla_nkifif none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ,I�No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes /Oho <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4i0e) (Continue on Back) -► -4. -► <br />