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(_2 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> VAtJh`e./ P. De- fires--r- <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Zoning Status; CUP; <br /> Deed Restriction; CSM <br /> 6790 Couh-ty /�'j'y V riance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> 6 6 - 5 Z - 6ZS ► 'ap-577-gy G W, y e di) tf/ G e irf,SA, D ke. SAt Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ,. - <br /> 'VI;k s Qua tit)/ A 00,t-i n y [Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> lt/41499eft/ Nw�, l+ <br /> (City,State,Zip) (City,State,Zip) Va./ / Setbacks <br /> PHONE P Al j� IZ4 ite Plan approval from <br /> ( C 4#, 6`4 /'f-Z applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> M ke Roc f,,h "ivfel/4 ,i cow moor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) L1d Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: p p rty <br /> U <br /> NUMBER 44/OSD7-092-747o-G b /J_Z 4`," frontage drawn to scale. <br /> TOWNSHIP: SECTION: I� <br /> 05 'A: N k/ % . S k/ riveway permits <br /> Y r m J'o5`�' /�' ` 4' a (state, county, town <br /> ADDRESS: <br /> 7 1 b et hills #4 LT 0 ( y town) <br /> CoOyy ou h� NO h �, <br /> CSM: LOT SUBDIVISION BLOCK/LOT V(publary permits <br /> 1 !if/,5 Lt, 6 t Nye <br /> fl (public, private) <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> R e.p a t c 4, <br /> dc r le,i4 s 6(Y!r40 t'h t 5h16'11 cc c ki Zo .ng District <br /> . L1 This project is a new building or structure. <br /> ermined Use? <br /> S.This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: 11�� PERMIT NUMBER: ❑ G Rural <br /> CI SEWER sa.SEPTIC (n- / in•) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 1 3 / a i et a i loodplain/ <br /> 1i'' oreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: j <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: , rosi <br /> ' onCOntrOl permit <br /> i 3 , L✓ th d e G 4, 1 TOTAL SQUARE FOOTAGE: + (Slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> C filling/access) <br /> 4F3 2, I1t> 'eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: c?�U t and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? C7 Yes LA No G Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®No ❑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 0 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 ®No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes allo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br />