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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C 'TOMER TO PROVIDE <br /> OWNFR NAI4F 1/ <br /> ElIZCt6e t 1 Her Ke 4 /t4IC/u € I V 1Lk VA Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 371/7 if,LL5Toi)E L-/1 1=oR$f WI. 53532_ Variance(# /1/35+{- ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 66/- $143- 1958 1;0 8'V q3 -195 ff "'IV i Cie- i ei 5C'a°C116•4't"V t let E Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> MtC1-t REL. V I CK 3lic k E MART,ki 5 uI LDi S Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3'NI MILLSTONE LANE 515 r'o J-rESi, J CCUR-f <br /> (City,State,Zip) (City,State,Zip) EKetbacks <br /> PE WJ. 53532_- MONTt cELLD wr. 53570 ,/ <br /> PHONE PHONE L,—V�Site Plan approval from <br /> (0 0% • g 4 3 - I ci S$ (pQ$ -576 - 2 9 9j 9 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRE <br /> rn v I C-k l q Sc/2 c h4r'ter.net J rh6 i.6IaerS Z-tctS . h Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) dElevation of property <br /> PARCEL NUMBER: CURRENT ZONING: ACREAGE: p pe <br /> [PARCEL 03S/07o$-ovq-0066-O R-1 I. V 9 3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ti-1 g p4 T �n <br /> 70Vv V DF M IDDLE-10Ni NE '/4: ,SE 1/'/.: 1.89 3 acre ❑Driveway permits a Y \ <br /> (state,county,town) <br /> ADDRESS: A1/14 Vc 2 / �^ . e i 0O NCN. D/S CSM: LOT ,lt+J /y e\�SUBDNI N W BLOCK/LOT IJa,anitary permits <br /> I'-13 5 y L OT 2- 14 t .ublic,private) <br /> u�olfif wo�oas rV ,4 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: -\ <br /> NEW RomE cowsTRI..c-rio l - , c.' C N 4oningDistrict <br /> . ®This project is a new building or structure. `., <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> 16:1Address <br /> EWER PEPTIC 13-2o 17 —0007�. /existing) <br /> HEIGHT IN FEET: DDDDDD������ NUMBER OF STORIES: (Not including basement) <br /> 2q FEET Z ❑ Wetland/ plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore d (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ (slope Control rmit <br /> I-1(p 1 l] Pf. 1 334 7 D P+ j r5TAL SQUARE FOOTAGE: + (slopes,di ante, <br /> 8 Q filling/ ) <br /> 2ND FLOOR: 3RD FLOOR: C <br /> 692 ❑Pt• N/A Z ✓ .-f--C"47— ❑ Review Location Surve , I b <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) -P. -, -I. '♦ - -0, 3 50j 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes talo [Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Egro [Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres Ohio <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 'lo <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 No <br /> 4t. <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) , i (Continue on Back) -∎ -► <br />