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ZONING PERMIT APPLICATION www.countyofdane.com Eri=31=7 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> N' C ❑Zoning Status;CUP; <br /> OWNER ADDRESS <br /> (Nu r,Street,City,State,Zip) Deed Restriction;CSM <br /> H2O RN' t ' Rp td, Mar-4)&0 ILA c o.i Variance(# ) <br /> HOME PHONE 4 CELL PHONE E-MAIL ADDRESS <br /> al' 0 A Sq-gec - d bi W SC I tl C& t fria-d- (OYVI El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> FV11 pumas-l- ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> cp-to Lo <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> IA OSSIV't _V t S- °I <br /> PHONE PHONE ❑Site Plan approval from <br /> (0 t)8' 22n 40 1 I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (ht :://accessdane.co.dane.wi.us/) n Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL <br /> NUMBER t l'2_- -V -2- A_� >pc,ftze 4,60 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Vied i ' '/a: '/'/: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> -, _I — • !i 4 ■ _.•_ 1 s5- .• ❑ '.anitary permits <br /> CSM: ••T SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> lGw ,\DIME. . ❑ Zoning District s414 <br /> . ❑This project is a new building or structure. U Permitted Use? A-1. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: , <br /> MEPTIC 13-- f Rural Address <br /> ^el 1 - 0 0' (new/existing) <br /> HEIGHT IN FEET: 3 NUMBER OF STORIES: (Not including basement) <br /> I{,^J 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 /> ❑'ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> C. 39 O' j TOTAL SQUARE FOOTAGE: j (slopes, disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: _ <br /> IAL\ ❑ Review Location Survey <br /> (Please CONSTRUCTION COST: ♦ and available options.■ <br /> Please round to nearest dollar) ♦ -P $$ J CCO <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 ❑No Ebon'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? ❑Yes ❑No <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? +Cam. . .:�bia•`., ❑Yes ❑No <br /> ` li0 • JV� ' St D,Ss%co APPLICATION MUST BE SIGNED <br /> 4S- <br /> OWattAprC S£'M..,IS 1:: CiNoUrik, (Continue on Back) -► ■ -i <br /> 545-112(008) <br /> `sue+ s. <br /> • IA ov St' 'pa-v)-11 • • A iNcltia i*w M 0- <br /> 5 I taw T-04)\-4- SV.11S1c.-rgAJlt, <br />