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'ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 12.14-41 Ka lq l L zoning Status; ��'. <br /> OWNER ADDRESS (Number,Street,City,State,zip) `./ ` Deed Restriction;CSM <br /> HOME PHONE � M C �e O ft . )E-MAILAD DRESS <br /> , vv I J ;J' Variance(#T O T L ) <br /> (SO$'88 0 Z 0.-Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO T RACTOR NA ME <br /> 1-kOWtwS 8eU L-e _ JC Lance-is LrOn S4ve L <br /> t vv LSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2120 Ni. ley- Si-. ctlit Aeale1a,--e ea. M,„1MV� <br /> (City,State,Zip) (City,state,zip). Z.Setbacks /v V <br /> C1iA tcu a ( L ( Ot state,AA 1.:8SC,A IWI j3 l3 <br /> PHONE I PHONE Site Plan approval from <br /> I T 3 -6� 3 - ' 6 o ('O£- Z7-I - 1-M(70 applicable township. <br /> E-MAIL 1 1 ADDRESS E-MAIL ADDRESS <br /> 4t 6 e�i e €SIC (OL I . h e+ ❑ Floor plans to scale �fA <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCELNUMBER: CURRENT ZONING: ACREAGE: ZElevatlOn of property <br /> ❑ NUMBER 0v i t.0g3_ S 1',lt'7' c A 'Z ) I frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> A ( 61 or, q 1/4: SW WA: ❑ Driveway permits NA <br /> ADDRESS: (state,county,town) <br /> Ct <br /> % NOL• t e 6'c0v C Rc ❑ Sanitary permits <br /> CSM: OT SUBDIVISION BLOCK/LOT N A <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> O ' •.nop ic a f ra.d o sine«er, area I� l e v-O>N� ❑ Zoning District ,.. <br /> . Z This project is a new building or structure. Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: ` ! A A PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC 14 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> S 4 e I - 10' I ❑ Wetland/F(oodpiein/ <br /> Shoreland (attachment)' <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: (' <br /> — 1.4 a s 4, TOTAL SQUARE FOOTAGE: 4, <br /> (slopes,disturbance, <br /> r <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 44 s C ® Review Location Survey' <br /> ESTIMATED CONSTRUCTION COST: ..+ .. --► ♦ ...o. 00 and available options. <br /> (Please round to nearest dollar) l , ��d <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IGI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? �4 e FQ , j� ('�O Yes ❑No CI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? C'�Yes ❑No <br /> 4. Has there been a zoning permit issued fo this property in the past 5 years? ❑Yes 0-No <br /> 5. Is this project associated with a rezon /CUP ariance(petition/appeal# x.01 L ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 121'No ❑Don't know <br /> 7. Is this to correct a violation? CI Yes CNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />