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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME f <br /> of tiC a bid / '4Y L opt ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,Ci ,State.Zip) Deed Restriction; CSM <br /> o(O Sut> s /"ail^/ fipad a Idpi ki Simz* Variance(# ) <br /> HOME PHONE CELL PHONE E-M IL•'DRESS <br /> /, O--911 7,7,22- a/ii, a, /if''1ci cem ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME C NTRACTO NAME' /� �j <br /> !DS ,)61 /I J'',/sin-- `S�/� ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDSS of well/septic <br /> Ai 7175- co um(?'/70 \T- <br /> (City,State,Zip) (Cit State,Tip) ❑Setbacks <br /> rf7�IS4 h 3 <br /> PHONE PoE �/� / S S�� ❑Site Plan approval from <br /> ao__ sG — 1/ / applicable township. <br /> E-MAIL ADDRESS E-MAIL ApDRES � `� <br /> el h ®/e f ay/4 6 ear .am ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: \ ACREAGE: <br /> ❑NUMBER D7 12 24""9080 A`Z�J ,r; y4/ frontage drawn to scale. <br /> TO` SHIP: 0 SECTION: <br /> 6r,!< r zf,f <br /> 1/4: '/.4%: ❑ Driveway permits <br /> (state, county,town) <br /> n) <br /> ADD RESS: <br /> -2be , J fr,p (1tlL' R mi GtkI,?12:0 G1/./' Vc 94 <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION , BLOCK/LOT (public, private) <br /> iZ /7O <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> PO jj ' ❑ Zoning District <br /> . lgThis project is a new building or structure. <br /> 01 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> (EWER mEPTIC / 3 - 2170••- Ono 75, (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES. (Not including basement) <br /> 1 / ' ❑ 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) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControlpermit <br /> ‘77 411 r 1 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: U filling/access) <br /> g/7 / ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ ^/ and available options. <br /> (Please round to nearest dollar) -•► ♦ ♦ ♦ ♦ ♦ $ P 16 Cb1) <br /> .1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Rif'o ❑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 iNNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#110/' . ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 1131 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 1 O <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -i <br /> 545-112(4108) <br />