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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> �/ /mi - A - M Zoning Status; CUP; C-72--- <br /> OWNER ADDRESS (Number, ,reet,tiny,State,.�ip) n [ ( Deed Restriction; CSM <br /> �/ >? lc-�' zC�l �� 3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL DRE S <br /> -es' 610 6 'lo tt v1 co '—4-s °"e2.1 <br /> " ni Site Plan drawn to scale j //_ 30 <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions I <br /> AGENT NAME CONTRACTOR NAME <br /> //////6014 13 - `& Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /Val s CO J evly '12— �2/3o�p ( 2 <br /> / (City,State,Zip) Setbacks <br /> (City,State,Zip) <br /> 1�c)5A2„3,rJ 60' 53 //t <br /> PHONE PHONE Site Plan approval from ,t(/ �(_ <br /> applicable township. y /'� <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ce$Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT P M Rh' n CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL r / i 9 d 0 c _ Z , 3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECT /1/F /�( �t <br /> o,,J � %: '/a'/a: ✓`Y Driveway permi A <br /> �- _ (state,county ow <br /> ADDRESS: / ' r I • <br /> CSM: LOT -�_ SUBDIVISION BLOCK/LOTS�' permits Ail <br /> t•ubl ,private) T <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: `1 <br /> C6 t.S 170 A-, ,4 1J 77 c.) 53 X� Zoning DistrictC 3 S <br /> . LI This project is a new building or structure. Permitted Use?�,d p( d--j <br /> ❑This project is an addition/alteration to an existing building or structure. �a„„,L ho Wit? <br /> SANITARY SERVICE: PERMIT NUMBER: ural • • '? <br /> SEWER ❑SEPTIC (ne existin. <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) /4-7 1 fet Wetland/Floodpiain/ <br /> Shoreland (attachmen) <br /> AREA TO NEAREST SQUARE FOOT: ` <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionControI permit A-- <br /> BASEMENT: 1ST FLOOR: <br /> yo n <br /> (✓ j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) i ' / <br /> 2ND FLOOR: 3RD FLOOR: <br /> �DDa <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: --0. ♦ ♦ ♦ ♦ ♦ $ 513-O 66 and available options. 4 <br /> (Please round to nearest dollar) �P <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ..61/6.... ❑Yes 44No LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? NO LI Yes gNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? .... XYes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes JO 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 _0 No ❑Don't know <br /> 7. Is this to correct a violation? . ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 2g, 6'0 (Continue on Back) ■ -P. -► <br /> 545.112(4108) <br />