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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT tc, Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN R NAME <br /> 5 to\te" I-/�l h I(k h 0 Z Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> HOME PHONE N. <br /> CELL ij i)(MA►LADD<0 SC wo, �r c3.75- Variance(# ) <br /> ( O '83 -6 ct II Co,-7 -bid . , ' (a k , Ina✓4✓. ne ef Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 54-ejern M Cl /0.y,A [4 Site Plan including location <br /> AGENT ADDRESS I CONTRACTOR ADDRESS Q_ of well/septic <br /> 3 I. !V, bv( Avn 4 1614 �,/V <br /> (City,State,Zip) <br /> r (City,Slate,Zip) Q 21 Setbacks <br /> b e'e r\ LJ A- 5-3 5- 7 5" <br /> PHONE l PHONE ❑ Site Plan approval from <br /> (2 O - D 6-- b 9 P, o� applicable township. <br /> E-MAIL AD)0 R SS E-MAIL ADDRESS <br /> w 11 A v% 49 - k a ' e 4Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NU :E'` CURRENT ZONING: ACREAGE: dElevation of property <br /> ❑ NUMBER 0 Sa./vs i 0 -1(032313s--0 k -�• ,5", 0 S frontage drawn to scale. <br /> TO SHIP: Q SECTION: <br /> (0w A C1- !,,+1,,N '/4: '/a'/a: Driveway permits <br /> ADDRESS: (state,county,town) <br /> riCSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> i ,�° 5 k A. , (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW f. -� <br /> PROJECT DESCRIPTION: 1 CI J e. i <br /> Din 3 I t x vv� ; . t 10" Zoning District ' <br /> This project is a new building or structure. V ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT UMBER: ❑ Rural Address <br /> ❑SEWER 0 SEPTIC 3-/ Z19 . (new/existing) <br /> HEIGHT IN FEET: // NUMBER OF ST 9 RIES: (Not including basement) <br /> ,Li Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: l ❑ ErosionControl permit <br /> d,0 0g ).. + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 9 1 o/� filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -11. -► ♦ i 5 O and available options. <br /> r <br /> (Please round to nearest dollar) f v 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes LNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Li Yes 4 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 ®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 4No LI Don't know <br /> 7. Is this to correct a violation? ❑Yes [4 No <br /> DR-E.,0 -1-04-4/ ?c- r I b4-3 g- 0 S L <br /> APPLICATION MUST BE SIGNED <br /> sas�t2laioel (Continue on Back) -► -to -► <br />