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• <br /> \,---- l; 7...owen . pT•4,T <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME \ <br /> 4 VEi Fi-&1jI`pA IRE(,BLE CRT t T izAseS } LI Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 5 /J Deed Restriction; CSM <br /> HOME PHONE c Ic4 sic- C,7�MAI�ADDR'5 3 &3 Variance(# ) <br /> .0T • _.:AP' LI Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ro5Eet6 o 7' ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /o$ol Co4+mays 43.eii,e <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> ArRQy ' LLE ( 7 5-'6.7g <br /> PHONE / PHONE ❑ Site Plan approval from <br /> 60 t• S7 y‘75.078. applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Gus /eoei ..v.CDC ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> RENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: LI Elevation of property <br /> NUMBER 65 ?07_.773 -$ c / ], /3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Root"'y '/4: Scu '/4'/4: Sc.0 ❑ Driveway permits <br /> ADDRESS: ( (state,county,town) <br /> CSf11/ kP LOT SUBDIVISION BLOCK/LOT LI Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> U SCC iv AN 6 tSTC A049 AN rENA/AE 7b T w <br /> FR ,Ty /,,?'X Xi Piet rE4 ❑ Zoning District <br /> . ❑This project is a new building or structure. LI Permitted Use? <br /> �is project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: �/9 PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER 1 LI SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /L^E'T EXtEt 10. Li Wetland/Floodplain/ <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: I—, <br /> ErosionControl permit <br /> i /x v�O�(91 j TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 9 Li 0 LI Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -4 ♦ 5-6©� 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? LI Yes LFS,N LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes L7No/o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? LI Yes ©1t' <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes <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 Ud1Vo fn ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 14115' <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -i <br /> 545-112(4/08) <br />