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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> 0Wr ly NAME <br /> lief 0. p4i_s.v1 Tr. O h 4 r /b' 'a 'n C ►1 m, Zoning Status; CUP; <br /> OWNER ADDRESS (Numbe Stre t,City,S te,Zip) Deed Restriction; CSM <br /> �1a� 'OOd' f et A r P/ o Zl, (05 1 S ariance(# ) <br /> •I ME PHON CELL PHONE E-MAIL ADDRESS <br /> P/ ^j1 -6760 . Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME COVRACTOR NAME <br /> r0. n � I <br /> K tt, 1 /' etc. S e Plan including location <br /> AGENT ADDRESS CO,LJTRA�roR s K f _cc I f / o well/septic <br /> (City,State,Zip) (Ci t te,Zip) h / etbacks <br /> PHONE PH NE 1::Site Plan royal from <br /> g©8- 3 Y5 - g 6 tE a applic e tow ip. <br /> E-MAIL ADDRESS E,,-Mq� LADDRESS / Floor ns to SC le <br /> JTRYr,e eo/ C ms 0 . eoM ❑ <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevati0 pro rty <br /> ❑PARENT PARCEL NUMBER: �CURRE ZONING: ACREAGE <br /> PARCEL ((llvv��, (0 (`i MR front dra to scale. <br /> NUMBER �� <br /> TO SHIP: SEC N: <br /> V u A n ,/4. SE ,/4,/4: SrJ ❑ Drive y permits <br /> (sta , county,town) <br /> ADDRESS: 1 <br /> at ! if ( 1)" k / P+. Dr , 6Y. u�i k lb h kJ.- • ❑Sa it. permits <br /> CSM: LOT suBODIVI�IOA ,N'1� tv� /�06 SLOT • <br /> p ,, ic, private) <br /> PROPOSED PROJECT INFORMATION WO.. <br /> ft-TAFF REVIEW <br /> PROJECT DESCRIPTION: r r <br /> / q ( ( � ! e, 0\Ct fitt fly ■ 'oning District <br /> . ❑This project is a new buil i g or structure. ❑ Permitted Us-? <br /> ❑This project i n additi Iteration to an existing buildi g or structure. <br /> SANITARY SERVIC : PERMIT NU B R: ❑ Rural As•reSs <br /> EWER EPTIC (new/exi. ing) <br /> HEIGHT IN FEET: ^ NUMBER OF STO IES: (Not including basement) <br /> t/J^JC/` ❑ Wetland/Floodplain/ <br /> Shoreland (attachmen <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached arages and above grade decks or porches) ❑ Eros 1 <br /> onControl permit '1 <br /> BASEMENT: 1ST FLOOR: <br /> ,l TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> , ----... M ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ -4. --lo. and available options. <br /> (Please round to nearest dollar) $ 10, DOD <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es ❑No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ©Yes Ri <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank' ne) <br /> 6. Is a location survey required? (see reverse) Efres ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> r J a - APPLICATION MUST BE SIGNED <br /> . n s I V�1 n (Continue on Back) <br /> 545-112(aroe) o <br />