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:16$111 <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> .3.-.4A/ 6 14,0 Y 14'= /Q'F-Al D Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,Ci ,State, ,,// Deed Restriction; CSM <br /> 3 7 `i C, 4 2 ylt/A4 L f&L,vr Tie. V,Clzv,.44 .5-3513 13 Variance(# ) <br /> HOME PHONE i CELL PHONE E-MAIL ADDRESS <br /> 'Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME (/�� CONTRACTOR NAME ,/(�� ` <br /> PIAsk /4 nlci f,2 s•✓ 14)o22Y r2F.. &11,406 ^„rf Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> .5.4.4--1,e Pd 4vy 93 o yi <br /> (City,State.Zip) (City,State,Zip) [rSetbacks <br /> o e j e r a,C. (/ 0. 4 9- W r- 5 3S9 3 <br /> PHONE PHONE I I Site Plan approval from <br /> 5,9-04.1 6 Os- 3-13 -3-6 5-4, applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS floor plans to scale <br /> r �1 0E n1 Nd.E.2 �,✓hv=��e ct.n atrL.ca <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: / CURRENT ZONING: ACREAGE: <br /> NUMBER 070$/203/a057/ 4 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ZID6( F TO yki At %:5L✓ 9,y 1/1/: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> Sg..>K-. <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> A Qu`, ►10 I C (public,private)ew <br /> PROPOSED PROJECT INFORMATION 11 t� STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> FZIr5 i7, 4 BA-s6,41.6 e%t- LJ Zoning District <br /> ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> HEWER rnEPTIC t{'( 3 D 9 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> L f ❑ Wetland/Floodplain/ <br /> V 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:Sc R,45 /304c.4 ❑ ErosionControl permit <br /> 1 Li i 0 s? �j 0 S f Pr 1 TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, <br /> / filling/access) <br /> 2ND FLOOR: 3RD FLOOR: no <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► -► -i -+ -► n n 7 b -0 and availably options: <br /> (Please round to nearest dollar) / ` /o. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes No ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes No ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Oyes INo <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) QYes No ODon't know <br /> 7. Is this to correct a violation? Oyes 5No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► -► -► <br />