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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM 1 <br /> li f L AI I e r (co 0 root iioc 4 Zoning Status; CUP; i 1 z y It <br /> OWNER ADDRESS (Number,Street,City,State, p) Deed Restriction; CSM 3 <br /> S-G C w, Man 51- II/14- 1`to,e 6 CU; -23, Variance(# ) <br /> HOM -HONE CELL PHONE E-MAIL ADDRESS <br /> I', 4/3}-5.5'34 ASite Plan drawn to scale / i/ / f <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions/ -7--- (r G <br /> AGENT NAME CONTRACTOR NAME <br /> J pit n /lar1( 'Site Plan including location <br /> AGENT ADDRESS / CONTRACTOR ADDRESS of well/septic <br /> 1. SN �—n6M t2 <br /> A A <br /> (City,State,Zip) (City,State.Zip) Ii Setbacks /0 e/q G1/O /o <br /> Sa,k C]JNE C,+, , 5 35$3 <br /> PH I we <br /> PHONE Site Plan approval from <br /> O' 61(,3.41 /09 applicable township. <br /> E-MAILADDR S E-MAIL ADDRESS <br /> ►■ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ` p P Y <br /> A <br /> j NUMBER ©4n6 (6-yq nol -i �/ , outage drawn to scale. <br /> TOWNSHIP SECTIO / <br /> r '/4: 5 IRA: 5 ‘,11 X D • ay permits G ZD mart 1 4 <br /> ADDRESS: <br /> (0x-16 � /&j ia9A4,llt (.c)t` �S3-CO / <br /> y ►. Sanitary permits 4, 6(fit CSM: LOT! SUBDIVISION BLOCWLOT <br /> (public,private) <br /> m <br /> /174k,4- <br /> j PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJyT L2P2i, 0 Q r Ge eP 2O V e—O3 y V Zoning District 2 <br /> _ <br /> This project is a new building or structure. ' <br /> Permitted Use? D �'This project is an addition/alteration to an existing building or structure. �I �, / ,f <br /> SANITARY SERVICE: PERMIT NUMBER: vCJ .FCural Ad•t • ``eGA'�✓� <br /> SEWER SEPTICak 4,tl'Ia`_ / <br /> HEIGHT IN FEET: ' NUMBER OF STORIES: (Not including basement) <br /> Wetland/Floodplain/ ) Y <br /> Shoreland (attachment)/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: / / /R� ErosionControl permit <br /> S C <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> <S 0 filling/access) -()Cl Q)95/ <br /> 2ND FLOOR- 3RD FLOOR: /(5 <br /> Review Location Survey A74_ <br /> 74 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) ♦ $ X10/000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,ZI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 4 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? A Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ,4Yes ❑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) ❑Yes iti No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IXNo <br /> 2xo + go <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/05) dry-na (Continue on Back) -► -i <br /> �a <br />