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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME � R 1�9 <br /> I\ I cLc, J V Gc" S 5 I 0 S El Zoning Status;CUP; <br /> OWNER ADDRESS(Number,Street,City State,Tip) ( Deed Restriction;CSM <br /> � g 8 5- fee)/ 5-'1- r ck, Rol' /na-S�a l/ (.-°% Ss'S 5-9 variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> O$ -ZZ5 x//2(0 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME , e <br /> 1 0 4 n U. C r sc S e r! [Y)0 r SC CA cc,-,S -er 84 /chry ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1' 3 5 `1 bNr u-e .'I�1 <br /> (City,State.Zip) „...- / (City,State,Zip) 0 Setbacks <br /> © eec--rieId (..) Z 553 <br /> PHONE PHONE 0 Site Plan approval from <br /> te 0 g - -7 G<(- To z5- Co 0 aj - (v `? & -- 77 Z 5 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> j nn o r c L 6, he+ v✓tek,1 , LD.vt ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 0 Elevation of property <br /> [NUMBER <br /> o 91 -3'/y_q 3,0 A- Z (.-z-- 3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Yo ('k, 3`/ %: s w ihih: .a 0 Driveway permits <br /> ADDRESS: 7 <br /> (state,county,town) <br /> ”' 3(0 e) �r+c G 1,t+{ '` 'b-- 0 Sanitary permits <br /> CSM: LOT /4- SUBDIVISION BLOCKILOT (public,private) <br /> !`f / 3 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: r <br /> New h o,., 7 t) l- SA e d ❑ 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: ❑ Rural Address <br /> EWER 155EPTIC '3 z61 -) _ boo 5-I (new/existing) <br /> HEIGHT IN FEET i NUMBER OF STORIES: (Not including basement) <br /> Z Z i ❑ Wetland/Floodplain/ <br /> AREATO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached ga es and above grade decks or porches) ❑ ErosionControl rmit <br /> BASEMENT 1ST FLOOR: • permit <br /> / 7 7 Y - l ,( ,'S ' I i. c 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> S <br /> 5 Lb L filling/access) <br /> 2ND'PtOOR: 3 n9/access) <br /> T ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and avaflable options. <br /> (Please round to nearest dollar) "� ♦ "� '� "� $Z S-6 odd. 0 d <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [ryes [DVo 0Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Do �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes a'Jo <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 [ilo [Don't know <br /> 7. Is this to correct a violation? [Yes a() <br /> APPUCATION MUST BE SIGNED <br /> (Continue on Back) -• -;► -► <br />