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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNERINFORMATION - CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> M '/ <br /> v `14' K G- , t'�s1a lI AZoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> (4,1 3 0), C-0,1 . -- }{w� `6 CD d,r, (,, .L 35-7 S Variance(# ) <br /> HOME PHONE CELL HONE E-MAILADDR S <br /> ,S)3 / 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) It—Setbacks <br /> PHONE PHONE Site Fin approval from <br /> aPpticable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> '---43 Floor plans to scale <br /> PROPERTYILOCATION INFORMATION (httpalaccessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> O <br /> NUMBER 0509` 7'1 `1710 _ 7 A-I E X {7R. 75 <br /> TOWNSHIP: SECTION: <br /> d u 7 V4: S t '/4'/<: S i= ❑ Drivewa ermits <br /> e..c]n (stat ounty,town) <br /> ADDRESS: `J y <br /> (Ok 32 Cv._) ,V/ 14�y <br /> SUBDIVISION -`) i �BLO- --__3� 7 ❑ Sa its <br /> CSM: LOT <br /> ® 161 ` (pu rivate <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> �,/ 'U A `10} M A\ S�,<. , n.`-� ❑ Zoning District <br /> . Ly 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: LI Rural Address <br /> ❑SEWER LIa SEPTIC ;`GLi3 1/3 9 (new/existing) <br /> / a( NUMBER OF STORIES: (Not including basement) <br /> rinicFrryirrec-- .7s 18- 42 / U Wetland/Floodplain/ <br /> 1 Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area ttached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 0 �� n//_ii j, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> ID (� fillingiaccess) <br /> 2ND FLOOR: 3RD F OO . <br /> /a00 17 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ -► Q� and available options. <br /> (Please round to nearest dollar) $ 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1�,10 CI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes D'/o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 1'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes ❑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) Li Yes L I o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 12<o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -9 -9 -9 <br /> 545-112(4/08) <br />