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1 <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> J;i1 fi5V,er ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ,Q Deed Restriction;CSM <br /> 5J1�f Coor a VWu P CcO t P1o.t o �4 555 Variance(# ) <br /> HOME PHONE x`.11 I CELL P NE E-MAIL ADDRES� <br /> ..2-57 _ ' • • 1 j If 1f.)b-CCOD ic dG -`C\ ,-t- ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> :s Deere lop"r,eN,r‘+ t Tv,C.. ne X Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 4010 E. Rt"i41'1CLYt Q `� <br /> (City,State,Zip) J (City,State,Zip) Setbacks <br /> 61 tae Mounds lei 73517 a ne (� <br /> PHONE t PHONE T Site Plan approval from <br /> (008. 1-13-1-&PA& j0.1-rle applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> rn e 1- • _ ., 1 •rhenf Co ! - 11,1 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 1 1/1 V •(�1 frontage drawn to scale. <br /> NUMBER oo4 08�7'a -Stoo"/ `1 <br /> TOWNSHIP. SECTION: <br /> b �_ 5� ,/: h1 _ ,/,/._ _ ❑ Driveway permits r1\0 <br /> (state,county,town) <br /> ADDRESS: <br /> 5135 CoOr J 4 t.A.)U P, CO CX Plains, 1)..)1 `>�-)Z,18 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) Yl'a' <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> QW Y�nmie Cr'RSIruC-it oi'\ ❑ Zoning 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: e_/ }-I(, PERMIT NUMBER: 1.3 Rural Address <br /> a SEWER 0 SEP (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> aq"5� 1 J J ❑ Wetland/Flaodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: 1--. ErosionControl permit <br /> 1 00l 1 1(1I + TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> L$ n\a 34 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ —0. ♦ ♦ —► ♦ $ , 0,400.GO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1,ANo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IA No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? W 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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 16 No <br /> -33 L APPLICATION MUST BE SIGNED <br /> 545-112(4/08) V (Continue on Back) <br /> �3 <br />