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<br /> ' ZONING PERMIT APPLICATION www.countyofdane.com
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> 1N /�
<br /> t�11 LUG --- M ��\1 r& ' e'' C 12 Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> p��c, 2_, .0 Grp J\ik) `n2 , V A , c Deed Restriction; CSM
<br /> c:? 'c'3 Variance Restriction;
<br /> )
<br /> HOME PHONE CELL PHONE Aft,— E-MAIL ADDREgS
<br /> .6 , -g4$-3%%'3 loft-220-$' 1 mke-MC t1v ( rem LI " corn ite Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME ,t/i� ,- CONTRACTOR NAME
<br /> �J 1��6 Ct,V►/� I`"�`-t.'1t V t'G \- \N-\a,,,` �j"A�c ,ex Site Plan including location
<br /> A NT ADDRESS Y CONTRACTOR ADDRESS of well/septic
<br /> 23° CZtIX-7- Utz i i2 2 3 0 2k t c3 "J ,
<br /> (City,State,Zip) (City,State,Zip) Setbacks
<br /> V t2,).-) 4- \N3-12or,\J' it w i
<br /> PHONE PHONE ®Site Plan approval from
<br /> AEI - 2- - 3I u,,c)e - 2-2.0 — goo) applicable township.
<br /> E-MAILADDRESS E-MAILADDRESS 1
<br /> C (iv @ WI Ct,`.cGI'h Vxc,,,,,\L t v l-,, g , 4t 1.cam /I Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usl)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 121 Elevation of property
<br /> PARCEL r �]
<br /> NUMBER Moil 040$'-NZ.553 1-3 �tt a.. )S 1,3 • 51-4 frontage drawn to scale.
<br /> rota SHIIP::0 SECT N:
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<br /> vt. l %: l ": Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> 10 N 21-Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> oZta 3 (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> IJe c.J 1 e_ Coil s'f'rt c"c_i;O✓1 ❑ Zoning District
<br /> his project is a new building or structure. ❑ Permitted Use?
<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT UMBER: ❑ Rural Address
<br /> DEV ER JEPTIC r 3--a0/ -0 L 5 (new/existing)
<br /> 511::,143-1 GHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> -2 6 - i 1/2 t t 2 ❑ Wetlan Floodplain/
<br /> Shoreland
<br /> AREA TO NEAREST SQUARE FOOT: (attachment)
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) E/C. aor 7-0 113
<br /> BASEMENT: 1ST FLOOR: -1' Po2G1.k ❑ EroSionCOntrolpermit
<br /> P-1474>i•t74> 2(p 8(p j, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance,
<br /> flllin
<br /> 2ND FLOOR: 8RD'FITIOR: (0.AQ.AE�E g/access)
<br /> 39-5`� `t y S� ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and available options.
<br /> (Please round to nearest dollar) $ `j Z y q 2
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es 3■o on't know
<br /> 2. Is there a wetland or floodplain on or near the property? Yes o on't know
<br /> 3. Have you talked with the township about your project and are they in agreement? , 'es Vo
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres a.
<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) EYes o aon't know
<br /> )7. Is this to correct a violation? ❑YesVo
<br /> I,„ ,3 , I APPLICATION MUST BE SIGNED
<br /> s,t,,,,a„,a,
<br /> 1 (Continue on Back) ■ —►
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