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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME C--\(\o- y ' 1 <br /> p`3 L-�`ttAi , s-„,\<)\-\ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Str et,City,State,Zip) Deed Restriction; CSM <br /> Li(oLVA P[e-2- IC� IA,6 leAcv\ U' , 5--. 5('. - Variance(# ) <br /> HOME PHONE (LL PHOON zD2 _ E-MAIL ADDRESS <br /> IU\J) s3?7 —"__, ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACT NAM <br /> A) ( akn ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS SC,SC of well/septic <br /> ` ,3b- 6reCLAls,i M }\uc ;c. <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE E 1� S3 s ❑Site Plan approval from <br /> 1).o - q S 0--13c)-- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS le,- dL{ CV&DicQ _ 5(kilSe <br /> l 0-= MA, 4. Cam❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> ❑PARENT PARCEL NUMBER: CURRENTZRRNIN ACREAGE:PARCEL _ <br /> NUMBER ,') ?D g (Z3 cO /7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /4: ,/4,/4. ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 1-/ 9 /CI se-1) {)-tc_----- P--X <br /> ❑Sanitary permits <br /> CSM: LOT BLOCK/LOT <br /> / <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> w'(\ --CiC ❑ Zoning District <br /> . ❑This roject is a new building or structure. <br /> ❑ Permitted Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: LI Rural Address <br /> FIEWER rISTPTIC (new/existing) <br /> HEIGHT IN FEET: p NUMBER OF STORIES: (Not including basement) <br /> 1/ ❑ Wetland/Floodplain/ <br /> 11 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: I-1 ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: v 1(, ��,\`O`,� filling/access) <br /> o� i Zv De(1( ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) d� 31 CCO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes Rio EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Efres Rio ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? I r'es 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) Dies ❑No ❑Don't know <br /> 7. Is this to correct a violation? EYes EtNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ <br /> 545-112(4/08) <br />