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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
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<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME `
<br /> Roit)41-0 4 �°A2o<y.J "l 7./914 ) , 0 Zoning Status; CUP,;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> Deed Restriction CS --
<br /> '5/63 ,504./ RA//?, o4 Q /JA j&kI OO & / 63. 95! Variance(# )
<br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS c_.
<br /> G")3 r IA,--/y o I,,GOw,/68 6�S^��5
<br /> ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> ROBERT Id. & ,-/ t )44-77._:--IS a110,,t'c 3 .,❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of I/septic
<br /> Po ,C3 a X .388' Po z3o x 2f8
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> /94_1-—J Tv3 C&/ 53009. A,cA E/ATO/J 4), ..33o0a
<br /> PHONE PHONE /-3'eo-SSf_78,00 ❑ Site Plan approval from
<br /> 46,2 -&70- 89g l -GA 9-,s sa/ applicable township.
<br /> E-MAIL ADDRESS ✓fjNS���Q He/$be ENILr DR S,L,,vi
<br /> ' Zc- 7 r-7c) 52 /a X td ' 4)A/, %Fe 8,040,,06.00 '❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (httpd/accessdane.co.dane.wl.us/)
<br /> PARENT PARCEL NUMBER: CURRENTTZONING: ACREAGE: Elevation of property
<br /> PARCEL ^ nA t�X rJ G'v frontage drawn to scale.
<br /> ❑ NUMBER 942 c 6� ,2—FS.r00-0 / GeiGUA,TEt.RAr- /,D /ziC/eE 9
<br /> TOWNSHIP: SECTION: iV W jy o f /1140 '4/ rx)
<br /> ycl2 K �6 A 9ZE 1/4: /J/Iy 1/41/4. Nee Vy .B Driveway permits 1:-)°7,u
<br /> ADDRESS: 1 (state,county,town)�p�/
<br /> '/'3 Su.tJP2A/2,F RoA',) )4 TE/C'Loo cam/ .513 51
<br /> CSM: LOT SUBDIVISION BLOCK/LOT 0 S�ryitary permits
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<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> S ja2f16e Z7/ZO CiriAC H/ti,6 .) ❑`Zoning District
<br /> El This project is a new building or structure. ❑'Permitted Use?
<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT NUMBER: ' ❑ Rural Address
<br /> ❑SEWER SEPTIC ■ ,•7 IBC Cr'c., I K_-,#' (new/existing)
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> /5'.S" To ❑ Wetland/Floodplain!
<br /> o nJ e- - Shoreland (attachment)
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> BASEMENT: 1ST FLOOR:
<br /> ❑ ErosionControl permit
<br /> 30/ K ./O ' 4, TOTAL SQUARE FOOTAGE: j, (slopes, disturbance,
<br /> 2ND FLOOR: 3RD FLOOR: /le)C: jF filling/access)
<br /> /°.7OO pi--
<br /> /- ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ -► o'a and available options.
<br /> (Please round to nearest dollar) ?,�'C 0
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? _ ra es t ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? >-15 I IoM / - f i s ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement?..G ral 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 aNd---❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes %o•
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) ■ -► -►
<br /> 545-112(4/08)
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