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4 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AME <br /> L>JC t. le-- ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> HOME!a 3 o CELL PHOty 5' ILADf el r n �I+ 3��y Variance(# ) <br /> 60 S.a de LucaSN'wrCY@•r1 '1'I•ec.+4 ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> kor- e itmAin %u■1dx.r- ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [' Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: <br /> Syr.,. CUR ENT ZONING: ACREAGE: <br /> ❑NUMBER oovesaa_3 ,-8. w-off A-a I q i7o frontage drawn to scale. <br /> TOWNSHIP: SECTION: fl;�, , <br /> Albion 3`/-5°la '/4: Ni) '/1/,: IJ 6 ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> Ia3 us ttM ti Ne(th E 9rr� s357Y <br /> CSM: T SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> N JA- (public,private) <br /> PROPOSED PROJECT INFORMATION / STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> eZ 5VOr KA-cttcrk + MA t--t r Ac\3tteo ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ Permitted Use? <br /> D,his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER MEPTIC VA- (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES:////(Not including basement) ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT Shoreland '(attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: <br /> ❑ ErosionControl permit <br /> WO(!O WO + TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> l filling/access) <br /> 2ND FLt40 3RD FLOOR: ' ^fp^ <br /> / Wl ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q �,r�l®� and available options. <br /> (Please round to nearest dollar) $ 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 0 o ❑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? igYes • o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes VVo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#601-0 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 0 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ! o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 ■ —► <br /> 545-112(4/08) <br />