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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> i <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> "k; t i - �1ie c,k . Zoning Status:CUP; <br /> OWNER ADDRESS (Number,Street.City,Stale, ) <br /> Deed Restriction CSM <br /> i 1 `'�) . v s�'k `. ' '1 C(C IAA S Y 7 C) 1 - variance(#__...____ <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> l Site Plan drawn to scale <br /> AGENT INFORMATION f CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME '50.Y"'0e CONTRACTOR NAME <br /> € r\ ( ,--y 4Iiv C• K j ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> i 41, `G. c-A. ) 't <br /> (City.State,Zip) SJ'f (Coy,Sate,Zip) 4 Setbacks <br /> PHONE PHONE ❑ Site Plan a oval from <br /> ‹ i l ..y,. ,, ce.c rt€.v.%.VS applica township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ oor pl to scale <br /> PROPERTY/LOCATION INFORMATION (httpctfaccessdane c o dane.wE.ust} <br /> PARENT :PARCEL NUMBER: CURRENT ZONING' _ -'41 ACREAGE: Elevation of pr erty <br /> ta PARCEL ER '( .14tC� 3?cOC e 3G-3 , ) S. ,,, frontage dr n to scale. <br /> NUMEi <br /> TOWNSHIP: SECTION: <br /> e "� ❑ Drive e <br /> T��, ':-.-.7-- ) 3 '/: � Vl� �l.'/4: l� � Y permits <br /> . t }- 1 G (sta ,county,town) <br /> ADDRESS: <br /> ("'1 S h L..1 5anita► permits <br /> CSM: LOT SUBDIVISION BLOOKILO <br /> (publ' ,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �" <br /> 5_.S 4"..i,. r(.. r:S K- :r s ?CU' n CC L. I a e("pre t Ve Soh 6$...5.(1 Q oning District <br /> . This project is a new building or structure. ' Permitted Use? <br /> This project i an addition/alteration to an existing building or structure. y ,�i <br /> SANITARY SERVI : PERMIT NUMBER: ❑ Rural i�rlre s <br /> SEWER SEPTIC ew xisti ) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) __ <br /> ' . i--- NUMBER 1 etland/Floodplain/ <br /> horeland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> 1".e,ri' ?rut. , ss- - K.;:�5K ErosionControi permit <br /> 150 s ,,, , t 4 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access <br /> w <br /> '� 7- "f, ❑ Review L cation Survey <br /> ESTIMATED CONSTRUCTION COST: -4. -4. ♦ ♦ _ and av able options. <br /> (Please round to nearest dollar) .,,,? i <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ! Yes ❑No L 1 Don't know <br /> 2. Is there a wetland or floodplain on or near the property? aYes akisto ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes (No,inc rat }ck� L� <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑YesNo 4177A ''' <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 ti No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes rjNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Sack) -4 -to -is <br /> 545.112(4/181 <br />