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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 /> ALb .-2—: 3:Drtg• ❑Zoning Status; CUP; <br /> OWNER ADDRESS ( mber,Street,City,State ,ic) <br /> /y9 y of „ f T f Deed Restriction; CSM <br /> 7 rLt' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> g77- ,3$ ( 2//-7469 /2,co7Ti.,t 4figoVia'ut-i--tc• /4 f Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ian including loc tion <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septi <br /> (City,State,Zip) (City,State,Zip) S aks c 0 <br /> PHONE PHONE ❑Site PI royal from <br /> ap li township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn El ation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y t.❑PARCEL / q1 I A' / Q y g R«� rontage drawn to scale. <br /> NUMBER �S/ � / /\ <br /> TOWNSHIP: SECTION: <br /> ' 00,4lv it-(e-_ IA: ih%: Dri rmits <br /> ADDRESS: ,�� (sta , nty,town) <br /> /VS2 Riols ,4-/11 A Crain 1,170. , W i .S S�, ❑s. . :-rmits� <br /> LOT it <br /> CSM: V SUBDIVISION BLOCK/LOT (p . c, •rivate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Coi-s in 1 q X a-t-1 * Dc ic Wing District <br /> . ❑This project is a new building or structure. 2n n C <br /> ermined Use?` <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> EWER PEPTIC (newefgtl <br /> HEIGHT IN FEET: )-3 NUMBER F STORIES: (Not including basement) <br /> Wetl plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorelan (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> Erosion■ • • permit <br /> BASEMENT 1ST FLOOR: <br /> 7 2. J I 4, TOTAL SQUARE FOOTAGE: 4, (SIO!-, • -tUrbBrlce, <br /> r filling/acce -) <br /> 2ND FLOOR: 3RD FLOOR:,--- 3. - <br /> view Location ey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �� a available option . <br /> (Please round to nearest dollar) P <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Ofro EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2lo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Eices ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 0o <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) Ekes ❑No ❑Don't know <br /> 7. Is this to correct a violation? [Yes 12no <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />