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C 2oo _ai (7,--ci <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME c <br /> L/-5A- 8 R-W J 07— ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 9'z 33 6-O(- Y gb. p4 14ZOMw1NIC- (,,.) 1 5.3 SLs, v V ance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> %2.36eP 6 V a 14 2 a z o o '' `',,,0 •C4.1tr k. ViSite Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ' -' -Y <br /> S ,eet&A`V (`�icstairf Uv2& Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS if well/septic <br /> 1 90 1 °5-/s—OC TE1 1{(5 <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> MT [-S0b0-0 L.. t 535 7 7-- <br /> PHONE PHONE N '•I e Plan approval from <br /> L 2.5- - ',I' 4 ap icable township. <br /> E-MAIL ADDRESS <br /> SMAILADD S <br /> St kL;M 1°1ei(6t "4ATIA12 M`'� F oor plans to scale <br /> o' Cit�(i 'rL, NCC- P <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of <br /> PARENT PARCEL NUMBER: CURRE 1 property <br /> ONING: ACREAGE: p p <br /> Li PARCEL . frontage drawn to scale. <br /> v <br /> NUMBER 07 oS3 <br /> isC�7C1 <br /> TOWNSHIP: SECTION: <br /> a�rzt�y , 1,4: r14 1�41�4: R 05riveway permits ' ' , ,s()\\,_(‘• <br /> (state,county,town) a 1 <br /> ADDRESS: <br /> 9233 -00-S7 Ro. <br /> CSM: LOT SUBDIVISION BLOCK/LOT re Sanitary permits <br /> 2 2 5 9 2_ (public,private) AV � li <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Nt '0 5 r 4.F, v)ti ridd 6 Bi,h./20&-D Do LAI • .71 g District <br /> . 0 This project is a new building or structure. UPermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: ,--,,/�- PERMIT NUMBER: ❑ Rural ' `• - <br /> ❑SEWER IL�rSEPTIC 57 t 63 6 ( = existing <br /> HEIGHT IN FEET: 1 ✓ NUMBER OF STORIES: (Not including basement) <br /> .2# tla ,./ loodplain/ <br /> PteLand (attachment) <br /> AREA TO' REST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) roSionCOntrol permit <br /> BASEMENT: 1ST FLOOR: (slopes,disturbance, 2 kJ l /O /#0? ( j) , TOTAL SQUARE FOOTAGE: 4, <br /> ting/ac cess) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Ga 9 C V�� q 2-`le. t :Review Location Survey <br /> ESTIMATED CONSTRU N COST: and available options. \tth <br /> (Please round to nearest dollar) ♦ -+ -+ -P -+ $ / 9 D, oat ' p`'J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes CBS No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2140 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes lallo <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 ❑No (Don't know <br /> 7. Is this to correct a violation? ❑Yes [ago <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />