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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> OWNER NAME.— 1 <br /> `>A"E L L . /'l C L LO oning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) n Deed Restriction; CSM <br /> 758 i--711---°7 - �p c-r_���o�, �� J 35 7S Var. nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS El Si a Plan drawn to scale <br /> (oG8 ZZI 94bq (US 770 99e9 tea t� 0 , ' ( L—' e..6_, <br /> AGENT INFORMATION CONTRACTOR INFORMATION a d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ ite Plan proval from <br /> pplic a township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZOING: ACREAGE: O <br /> ❑NUMBER (4 1 n d?._S.'O OC" ^ ' ..� frontage drawn to scale. <br /> TOWNSHIP: SECTI �1 <br /> il n n 1/4: 6 '1., 1/4'/: /U ❑ Drivew permits <br /> ADDRESS: (stat ,county,town) <br /> a ? ' ) 1C 1 ©'r ❑Sanitary mits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> publi , rivate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO CT DESCRIPTION: (:)) .x t� <br /> 1�O 1U(\v) I if a' ,oning District <br /> . gi This project is a new building or structure. a Permitted Use? <br /> ❑This project is an additio alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural tr a-zs. <br /> FIEWER EPTIC V v (new/z' isting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not inclu J ng basement) • <br /> ❑ Wetland/. ...plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shor .nd (atta« meet) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) .---, Erosion tr01 permit r <br /> BASEMENT: 1ST FLOOR: <br /> a , TOTAL SQUARE FOOTAGE: 1 (slope "isturbance, <br /> 2ND FLOOR: 3RD FLOOR: filhn• -CxeSS) <br /> C9 q U ❑ R-view Location Sury <br /> ESTIMATED CONSTRUCTION COST: and available options. ' <br /> (Please round to nearest dollar) ♦ ♦ —01. ♦ -� ♦ $$ S cy)CD <br /> / <br /> 1/ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes go ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? files ❑Nof <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank iI'none) <br /> 6. Is a location survey required? (see reverse) Ekes o ['Don't know <br /> 7. Is this to correct a violation? Elves No <br /> '--(C:( r c APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) G, ,s,?' <br />