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• • <br /> ZONING PERMIT APPLICATION www.countyofdane.com F3:31233111==n <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N ■J■ N1Us LLc:.. <br /> --------- ❑Zoning Status; CUP: <br /> OWNER ADDRESS (Number,Street,City.Wte.Zip Deed Restriction;CSM <br /> HOME PHONE ��� PHONE _s 04).940(•, �D( s3 Variance(# ) <br /> 1 <br /> - , , - , .. • I J A �. A-, ,..s..ri , .,-01:1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR R 4FOR'.1ATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> bdt).-0k ❑Site Plan including location <br /> AGENT ADDS TCONTRACTOR ADDRESS of well/septic <br /> 10 1 PI s!_._ <br /> (City,State, h.kd1 WS (City,State,Zip) ❑Setbacks <br /> S 53L589 <br /> PHONE 1 PHONE ❑Site Plan approval from <br /> D _ applicable township. <br /> E- IL DDRESS E-MAIL ADDRESS <br /> 49 +-. 9 r,,_,„ 1_. .m. <br /> Floor plans to scale <br /> PROPERTY/LOCAT',ON :!J=ORMATION (hitp://accossdano.co.dano.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING ACREAGE Elevation <br /> drawn to property <br /> ❑NUMBER 1`_]o 06i0-'Ot1"7�11 LM <br /> TOWNSHIP: SECTION- <br /> R ` �4 ,�,: 1�41�4: ❑Driveway permits <br /> (state,county,town) <br /> ADDRESS' <br /> ''s7 OA O ' hr____-- __..-------__-.--_ — ❑Sanitary permits <br /> CSM: LOT SUBDIVISION 1 BLOCK/LOT <br /> i1 94 t (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE T D�ES1CRIPTION -h <br /> 6\,R, SA-0?-0-14.._. 60,:, ao X ls0 D 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 — 1.3 Rural Address <br /> FIEWER rEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES (Not including basement) 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) U ErosionControl permit <br /> BASEMENT 1ST FLOOR <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR 3RD FLOOR ( 00 <br /> 3 U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST -+ ♦ -' ♦ -+ ♦ n�OOO and available options. <br /> (Please round to nearest dollar) €t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves 'lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes no ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? D es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 02 es Ilo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) <br /> (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Elves SW) ❑Don't know <br /> 7. Is this to correct a violation? Dies 'lo <br /> cl � APPLICATION MUST BE SIGNED <br /> V �� (Continue on Back) -► -+ • <br /> say-112 ialUBl V v3 r <br />