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f 56 Lfa 22"1 :1 * Z 35 aro° GI <br /> • <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1GU/ <br /> OWNE DRES Nu e Z V • 'v1/ [l Zoning Status;CUP; <br /> 'V( Deed Restriction;CSM <br /> � � ( Cl y PHONE �� E-MAIL Daes r ��1 53W3 Variance(# ) <br /> PH -7 j� //� AQ J r <br /> l , ■ I 1 • r1 .1 0✓J'1 U 11-1/[/ ('t 1 h fa /('eirn4 [ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [l Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (city,State,Zip) (City.Sate.Zip) vi Setbacks <br /> PHONE PHONE 4,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/) 0 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER frontage drawn to scale. <br /> ptd —b5l—Qhf�P -l ►� ����3 1^p�I <br /> TOWNSHIP: SECTION: <br /> V U _rob N�O8E o ' : SE �� : NE <br /> Driveway permits <br /> AD $S (state,county,town) <br /> 17 r oUuti 1k&(d( uJ ""^'4I JQi'DL41t ( VV 1 ❑S i p=its <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 01335 2 (P n = -) - <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: II <br /> 51A Q(,l 1,,t ► X 440/ ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> QThis 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 �,`�4 NUMBER OF STORIES: (Not induding basement) ❑ tlandlFlood lain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland <br /> (attachment) <br /> (Outside dimensions induding unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> fllling/acoess) <br /> 2ND FLOOR: 3RD FLOOR: C� <br /> ` 610 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ _� _� ♦ --0. <br /> and available options. <br /> (Please round to nearest dollar) $ 15; DU(, <br /> 4122 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [-Yes [ lo 111)on't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes flo [on't know <br /> 3. Have you talked with the township about your project and are they in agreement? OYes alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Olo <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 Jlo COon't know <br /> 7. Is this to correct a violation? ❑Yes }lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545-112(4108) <br />