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r <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTO • • • - •VIDE <br /> OWNER NAME . <br /> k�I WO <br /> Pr'il Irr AS ).,1..<._, 1► <br /> Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip Deed Restriction;CSM ki 156 (rinrvir`h�a�/ Variance(# <br /> HOME PHONE CELL PHONE E-MATA�DDRESSr-� <br /> afi`'4' ` V a • .•:-a a5 • f �Mu 11-� cic( • A0�+ P Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ` CONTRACTOR NAME <br /> `IA me'S Ju"l✓ � <br /> Site Plan including locatio� ' <br /> AGENT tr3Fossf, CONTRACTOR ADDRESS f well/septic <br /> 61:1K 67 <br /> ‘3/3 0(City,state�zie) T. (City,State,Zip) Setbacks /0 7 co,'tjs4 <br /> r...t cY 4erm WI- <br /> PHONE PHONE XSite Plan approval fro 4._ <br /> c(5s sgy -- c1 C( applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale / <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: X property <br /> wPARCEL ER lJ g 11 frontage drawn to scale. <br /> NUMB W `���5.� -ciao-0 / 1 I <br /> TOWNSHIP: i - SE N: Q � � ) <br /> 1 �� %.,ih: 5 VU %1/4: S W XDriveway perm' : Al <br /> ADDRESS: (state,county town 'v <br /> IS Co.v,',Ai), � 11 w� (40o,"L w 53g`' 1 <br /> CSM: LOT Y SIDDIVISION BLOCK/LOT ❑ Sanitary p--:-Is �q 0 <br /> (public, ■rivate �/ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW k1��� <br /> PROJECT DESCRIPTION: <br /> S _ ''jam' `�- Q <br /> Ov'AIcC ` A io 'l k i cy( k V'i- Zoning District 4 — ('),Q I, <br /> ziThis project is a new building or ructure. 3 2 o <br /> ' � frPermitted Use? o� <br /> ❑This project is an addition/alteration to an existing building or structure. _ <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> RuralAs•.- <br /> ❑SEWER ❑SEPTIC n- 011 ■ <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) - ' -, <br /> 4 <br /> ❑ 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: / ' <br /> ,` II Erosion ontrol permit d i <br /> y TOTAL SQUARE FOOTAGE: (Slopes,disturbance, <br /> uuu filling/access) /) <br /> 2ND FLOOR: 3RD FLOOR: I/6 ;/ <br /> ESTIMATED CONSTRUCTION COST: 1000�J it l Review Location Survey A <br /> .♦ .♦ ♦ ♦ ♦ ♦ 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? ❑Yes tg No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 14 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? IS Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? IS Yes ❑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 N No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -4. ■ -► <br />