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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 /> '°'e`n'c.i "S \v,Ier r-Ai oning Status; CUP; <br /> /NERADDRES (Number,Street,City,State; i ) Deed Restriction; CSM <br /> � v1ie (,� �5e ��h�n�) \/✓I5�3 Variance(#E PHONE CALL PHONE E-MA ADDRESS / <br /> -03 7!2--7y�'1 OUn i.�/, 1- ©6-It-lc..,./c-c3 ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> A NT NAM�j CONTRACTOR NAME <br /> ljant c1 3 W;ppl: -r h Si an including location <br /> AGEIgADDFESS CONTRACTOR ADDRESS well/septic <br /> i/�1/e7 t.JVC?s O' <br /> (City,Stat ,Zip) (City,State,Zip) W etbacks <br /> PHONE / El Site P n proval from <br /> 6w) 7`�— ?gs '' applic etownship. <br /> E-MAIL(RDDRESS E-MAIL ADDRESS ,. <br /> OUP . ,, Ci-lnte0i7 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Eleva n of property <br /> PARENT PARCEL,NUMBER: CURRENT ZONING: ACREAGE: q <br /> ❑NUMBER c�.S 1/)709-3Z-I161-6 R— ( 4t{ c S / fron g drawn to scale. <br /> TOWNSHIP: SECTION: <br /> �1, zlloi ,/4. 1/41/4. El Drive permits <br /> DRESS: (stat , ounty,town) <br /> 41,?-5 V /ley wo S die- <br /> 1=]Sanl ry ermits <br /> CSM: LO SUBDIVISION BLOCK/LOT <br /> - i ltd (q� b (publi private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION' <br /> Dedk 0- x J C _ on g District <br /> This project is a new building or structure. t ermitted Use? <br /> This protect is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EPTIC / 14 (new/e,01fo:'.-vp <br /> HEIGHT IN FEET: NUMBER OF STORI S: (Not including basement) <br /> Li Wetlan•""�.odplain/ <br /> / Shorel. d 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: ❑ Erosio ont••I permit <br /> J + TOTAL SQUARE FOOTAGE: 4, (slopes,dl urbance, <br /> 2ND FLOOR: 3RD FLOG filling/ac <br /> �� ❑ Review • ation Survey <br /> ESTIMATED CONSTRUCTION COST: Q S 09 and ay.. :ble options. <br /> (Please round to nearest dollar) -� $ ��J v`� \ 4, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a and or lake? es o Don't'k ow <br /> p p y 3 et o ea 0 pond ❑Y �I ❑ <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 'lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Llo <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 ENO ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ENO <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) --i - -s <br /> 545-112(4/08, <br />