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e63__ v...._ , <br /> . -) 0 ) o5q ( <br /> C <br /> ci,„4,01)- i e C)(1 q,� 2 (2,S(2 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Wen-App <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> &V l I Io Ton()ii 0. oning Status;CUP; <br /> OWNER ADDRESS(Number,Street,C ,State,Zip) Deed Restriction;CSM <br /> 83q�( 160/a I ' I Jlo _ �-Z S35- 3 Variance(# ) <br /> HOME PHONE LL PH E E-MAIL ADDRES� <br /> "3, -66- 5 o 5? -906-s- 1 kI C k i Ow j sc., (ci V r■ ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Da.,l tI0.V'f 6Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 8967 i1irbov,Tv-at_ce <br /> (City,State,Zip) (Qty,State,Zip) '1.4 Setbacks <br /> PHONE PHONE Site Plan approval from <br /> 6o g_[f g t(_o(a 3 applicable township. <br /> E-MAIL ADDRESS E-M.IL ADD RESS <br /> • QC. "Q - - ® 4 Floor plans to scale <br /> �c <br /> PROPERTY LOCATION INFORMATION (http:. accessdane.co.dane.wi.us ) 11l Elevation of property <br /> PARENT PARCEL NUMBER: CURRE TZONI G: ACREAGE P Pe y <br /> U PARCEL NUMBER CGo7«�3-93Yo-p , /O, 93 <br /> frontage drawn to scale. <br /> TOWNSHIP: SECTION: - ! C <br /> SPr t 14 a � _1 e &— 1% S'KJ 1/41/4. (..,<_) iveway permits <br /> state,county,town) <br /> ADDRESS:3f 4( 4'1414 kc! //,,- � <br /> CSM LOT SUBDIVISION BLOCK/LOT <br /> unitary permits Gz (-4.0 L `t <br /> Y5, a (public,private) r <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Poo( -t,So h v'oOk4 t tho 4 oning District <br /> . ❑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: , }f� Rural Address <br /> ❑SEWER 6EPTIC t/ (new/existing) <br /> HEIGHT IN FEET / NUMBER OF STORES: (Not including basement) <br /> a Ylie l ati' 22- a ❑Wetland/Floodplain/ <br /> Sh eland <br /> AR A TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) E rOSionControl permit <br /> BASEMENT 1ST FLOOR: c',,,�, <br /> N�d4 II a 7 o C�31�( j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> FLOO'• • 3RD FLOOR:,/ j/� XL I' <br /> filling/access) c�� <br /> ...or `� ( / 1"( view Location Survey <br /> -TIM• ED CONSTRUCTION COST: available options. <br /> -4. -0.round to nearest dollar) S VC)d 1 ©d ,o c <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? U Yes ®No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ®No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑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 IN No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4Ne) <br />