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� ^ / 1 <br /> d-C.1 / <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME r� CUSTOMER TO PROVIDE <br /> V"ICJ t 1 lC�' C .,\ M V'T <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Zoning Status;CUP; <br /> .S3 Cv- Ci A / \ S-55°1(-1 Deed Restriction;CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS Variance(# ) <br /> 9 LC)06 i 132 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> AGENT ADDRESS Site Plan including location <br /> CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) <br /> (City,State,Zip) EkSetbacks <br /> PHONE PHONE Site Plan pproval from <br /> applic a township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS - <br /> ,a\Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) . fit <br /> 0 PARCEL <br /> PARENT P,:. c • CURRENTZO ING: ACREAGE: Elevation of property <br /> NUMBER 071)- —a1/-P' <br /> 80o r- A s frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> DeQf'r;e /Ci -)-L1 1/4: N f' %1/4: N1 - Drivew ypermits <br /> ADDRESS: (stat ,county,town) <br /> ;\r .0 3 (,//-1 0 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ,S Ita permits <br /> publi ,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: STAFF REVIEW <br /> ille �tl.. ` C f o ••—/ RD^��Z—c w2■ `21. Zoning District <br /> ❑This project is a new building or structure. <br /> Permitted Use? <br /> JaThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> ❑SEWER ASEPTIC (new/existing), <br /> HEIGHT IN FEET: 9 NUMBER OF STO IES: (Not including basement) <br /> j 1 U Wetrand/Floodplain/ - ;N(2 <br /> AREA TO NEAREST SQUARE FOOT: Shorefand (attachment) 'PrA <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) . ' <br /> BASEMENT: 1ST FLOOR: ErosionCorntrol permit -\ <br /> O p j TOTAL SQUARE FOOTAGE: ,l slopes,/� sturbance-, <br /> 2ND FLOOR: 3RD FLOOR: fllling/access) <br /> ESTIMATED CONSTRUCTION COST: `� Review Location Survey, <br /> (Please round to nearest dollar) •' " ' ♦ -► -■' �9 )/ s nd available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes otrei <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 -No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes .No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) (Continue on Back) -► -► -÷ <br />