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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> KT Q E ) gzoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> ) 6 2 6 0, *� a C sse, �� S'f 6 C 2,— 2.107 Varia nce(# " f ) 5 <br /> ) <br /> HOME PHONE CELL PHONE E-M,41L ADDRESS <br /> , 0: —7$S- 4c1$; 6n■ --793-C-/-X1' -r-co... , 1Lw>� -�- ' 4 (AV 21Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT ME CONTRACTOR NAME <br /> -e4 Co re A-v.-6-- tL0✓, K tAW;c I y,te. e, Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ) 626 O c. k Sri-, 16 2b O a S <br /> (City,State,Zip) (City,State,Zip) g.Setbacks <br /> -c., C,-o $.Q j . (4-602-72-107 1^4 Cr-40‘442)1,41 5 Li(o o2-- z l c <br /> PHONE PHONE ❑Site Plan approval from <br /> (0 0$—'7c 3 _S`1"j(0 6c 8"- ')6t 3 — s--(—)L applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> +C o • is ►Ly,r,)L+,,,, - .,erx,w, 4- C o ra 0_‘2_04,V__4,,.. , , Cv►tip 10 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑PARCEL S- x°0-0 c� 6— ) � , )2 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> [? ( ° 8-2�jz-810 s— 5 e.� ` °'C of ['Driveway permits <br /> ADDS: a O�1 C a z �4. �4�4. <br /> (state,county,town) <br /> 7C-3'1 M/, h1 i nerPb1 SoQ;4- I. V e .0>1.k) ' <br /> CSM: LOT SUBDIVISION BLOCK/COT ❑Sanitary permits <br /> 7 CC ) Z (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Lk) - <br /> CO /C ,*„∎ r." -v-(----- ❑ 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 [)EPTIC (new/existing) <br /> HEIGHT IN FEET 14t NUMBER OF STORIES: (Not including basement) <br /> ❑ 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 /> BASEMENT: 1ST FLOOR: ❑ <br /> ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �^ and available options. <br /> (Please round to nearest dollar) "♦ '♦ ♦ ♦ _p -► $ -/v d00. r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Eiklo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Oslo EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes Dlo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes EiNo <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 [plo ❑Don't know <br /> 7. Is this to correct a violation? [Yes "lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -♦ <br /> 545-112(4ro8) <br />