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' SUPPLEMENT to Web-App # <br /> • ZONING PERMIT APPLICATION www.countyofdane.com <br /> . PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER ; // E ,c ti (4.1 e,•.l a rJi Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Str9strCity,State,Zip) // Deed Restriction;CSM <br /> 17 y rtrt - 5� �re - // , Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL <br /> 7• 5-4-3 - I <br /> Z tea'r'y ile ri-11)-1. 'i jg Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> KcA J A.J L. GR o r/tEt.5 y o yb g Q2 Z)v, ( 5 /: Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> a3/" /►1f.)ley 12C. JSav (J . Ali") 5--1--. <br /> (City,State,Tlpy, (City,State, 'p) 4 Setbacks <br /> SSA./ 17r4.:(ce w1 Sys 70 SJ,� Yr ` ;c c..)1- 535-70 PA- <br /> 624 . <br /> PHONE / it PHONE ❑ Site Plan approval fro 1)-S V09-- • 2 Z.i 4 o8'. Sa y�yam- applicable township. 7 <br /> E-MAIL ADDRESS E-MAIL ADDRESS I i. <br /> C.ro-t- 5—@ IA A o I , co,".._ • , 8,t, L <br /> at � .,,,(, Cev^',_.6 Floor plans to scale (pr. <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane.co.dtane.wi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: A Elevation of property `.V <br /> ❑ PARCEL <br /> NUMBER 11 -I L -1 - /STY c( A(T ,, if frontage drawn to scale. <br /> NUMBER (� <br /> TOWNSHIP: SECTION: 7 3 7 ` <br /> Li T/5 +0 I I Z 1/a: H '/.'/4: 5-E LI Driveway permits 7 <br /> (state,county,town) 3 3"4-/ <br /> ADDRESS: <br /> ('R--5b / JAM - v - i tvtA-v Tr. <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> 7 1 0 2- /v.X hi;//j (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION p / <br /> N C� Si X51 ;~-1/A-6 l y I� .L 7I A_/ ❑ Zoning District <br /> . /4 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: ❑ Rural Address <br /> ❑SEWER SEPTIC 57' 0( O (new/existing) <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not induding basement) <br /> a g Z ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 15 ^ ' n' 1ST FLOOR'. -7 p' <br /> vl tI/ TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 1 S L r/�j A 3RD FLOOR: ��/� R i flling/access) <br /> ` f ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ' - and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ -•► ♦ ♦ $ Dar-4_/ Q�C� . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ONo LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ONo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? gYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes A 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 4 No ❑Don't know <br /> 7. Is this to correct a violation? CI Yes yi No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/05) V57. 0 0 <br /> (Continue on Back) -I. -► -► <br />