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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N �// <br /> e,/ "(7e9_-/' /a" — ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number, r -t,City,State f,J,�'"(� Deed Restriction;CSM <br /> 2-r 00 W s Variance(# ) <br /> HONE C LP ONE E-MAIL A9 DRESS y/ <br /> �3r✓i �.- „-z /a L'1,c4. h i ,e;k4.4 cs` , cei44 ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGEIANIE �/ CO T R NAM <br /> A G,( Ev//4 [,C,cdp Site ' -• .1 luding location <br /> AGEt+�T ADDRESS ' / CONTACTOR ADDR sS , , O ell/septic <br /> (City,State,Zip) _ (City,State,Zip) ❑Setbacks <br /> ' % -�/.moo 1,, i-e1l x`'7/7 "1-11 . %122vl'C S7l/ <br /> PH `, ` pH ❑Site Plan approval from <br /> mod') lam/f 7/7/,/, Z�,j `'( 9 475,7-7,,r applicable township. <br /> E k ADDRESS 7,1,/ —e / E-M 0 DRE ❑ plans� � �„ � el-- �, �� Floor tans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONIN AC E: <br /> ❑PARCEL 136/D,/f 65J 7 .121/f FMS frontage drawn to scale. <br /> NUMBER ! //�� <br /> TOWNNSHHIP: SECTION: ) <br /> t4/h 6 e//1 .P.. /9' 1h: /' 2 1h1h: ,,y ❑Driveway permits <br /> AD /RESS: (state,county,town) <br /> l zYLV 'VA'/ . D�� J i ZISanitary permits <br /> CSM: LOT SUB IVISION BLO LOT <br /> 9 �ta o/ j, , •� �i (public,private) <br /> c' mot' ' / / <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> / //l° ' A-04--e- 4 'l ` . t// ❑ 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: PERMIT NUMBER: Li Rural Address �+ <br /> EWER kigEpTic J+ 1� <br /> / qo (new/existing) ^-!1 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) pi <br /> ❑ Wetland/Floodplain! <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) EIOSlonControl permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: Ming/access) <br /> ESTIMATED CONSTRUCTION COST: /� r 6o ❑ Review Location lep Survey <br /> (Please round to nearest dollar) '� ♦ -+ -♦ —■ ♦ $ 6. ��� - and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes I ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yep o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 2fes l�v <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if no ) <br /> 6. Is a location survey required? (see reverse) ❑Yes a on't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i ■ -+ <br /> 545-112(4/08) <br />