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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 /> P4-TTEiu A-ui, 4- gtnor Ni co <br /> 1 ❑Zoning Status; CUP; <br /> OWNER ADDRESS(Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 70355- RESTJJ i-il€iG/-ITS t I v5,/I'I4DISLW, W/ 5-3 716 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 13-0/3- N RI tJ O ! , , ♦/k y . CM [Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> CIA- 51e_C C�r�`�Tam u(jfe-3 EiSite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 10/ N. C'C,uZ Avevl,6. <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> // <br /> PHONE PHONE A/ i Wt S 9 Site Plan approval from <br /> 60 _857)r 11460 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> [Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> 0 PARCEL <br /> NUMBER 0/80111 oSwZl lSO 1a-1 I.(0 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> errfi;E aQc -ro—f J ei1 05 1A: N W '/4'/4: Sg Driveway permits <br /> ADDRESS (state,county,town) <br /> SAM17pj10 ' •ThAI L 0OT7 • 6 a°Ve. , IN1 silL ❑Sanitary permits <br /> CSM: 1 LOT SUBDWISION BLOCK/LOT <br /> •' ,6 . Ikra0.' a'sl..,.. (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 2,,mIt`)Cj)C ❑ Zoning District <br /> . ,'Phis 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 NUMBER: ❑ Rural Address <br /> EWER REPTIC 13-'201'}-00189 (new/existing) <br /> HEIGHT IN FEET: C NUMBER OF STORIES: (Not including basement) <br /> t .1 Li Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attach d arages and above grade decks or porches) <br /> a:1/1,s ��,// ❑ Erosion Control permit <br /> BASEMENT: <br /> 1ST FLOOR: + TOTA gQUARE FO TAGS: ,, (slopes,disturbance, <br /> 1r0 SF '-Z 1X5 SF �l filling/access) <br /> 2ND FLOOR: 3RD FLOOR: .-4-46-1t- <br /> SF ❑ Review Location Survey <br /> (Please <br /> ESTIMATED CONSTRUCTION COST: —I. -► ♦ —No. ♦ �!O 0� and available options. <br /> round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Ekes ■ 1 o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes alo <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 ∎,4 o ❑Don't know <br /> 7. Is this to correct a violation? DYes E o <br /> i,.5. j I , APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />