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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME q
<br /> 5°
<br /> Al Pc1. 1,—)e4/7 ❑Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City, e^Zip)
<br /> ,� �/ Deed Restriction; CSM
<br /> 7.,-" L 1 ,i ; ` /J/o o, p, L-c ZT Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL DDRESS
<br /> .--, n8;f,53-97`/-? a,..,26,J/o?bv8 e' a.1i.4:0.i i 4 ❑Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT N ME CONTRACTOR NAME
<br /> AGENT 7,:?.Q / (Ye ec ' I: ,4,/, /o-/ ❑Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR DRESS of well/septic
<br /> /.15U J.'a,i� 1 n. /9U "c7 // . /M A-1>3oa, 6,
<br /> (City,State,Zip) (City State,Zip) ❑Setbacks
<br /> q f
<br /> PHONE _ PH NE ❑Site Plan approval from
<br /> �Gi' 77/ .6 3-?-- 613" f/S= 9 TZjCj applicable township.
<br /> E-MAIL ADDRESS
<br /> E-MAIL ADDRES� /
<br /> di,,,./ a/Pc., J,,/J4 • CDC dz�A ( ��c/P
<br /> C-'� . •// '. row ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT�75ON NG: ACREAGE:
<br /> ❑NUMBER S6 °/ �,3 I�( O 1�l�/ z , (�, frontage drawn to scale.
<br /> TOWNSHIP—' SECTION:
<br /> <Q4> GA,/ Zj/e5�y> • 3,�, ,A. ,/4,/4: ❑ Driveway permits
<br /> ADDRESS: /
<br /> 00 (state,county,town)
<br /> Z WI?)04 4/ ile- /c,h, LJ-7- --r- ❑Sanitary permits
<br /> CSM: LOT J SUBDIVISION BLOCK/LOT
<br /> (public, private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> _rb?<,30 o1la r .5 >DD
<br /> ,a•,5 ( aD Li) ❑ Zoning District
<br /> . This project is a new building or structure. LI Permitted Use?
<br /> This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address
<br /> ETEWER r)EPTIC /'0 (new/existing)
<br /> HEIGHT IN FEET: _ ,/ ,.// NUMBER OF STORIES: (Not including basement)
<br /> 1// / ❑ Wetland/Floodplain/
<br /> Shoreland (attachment)
<br /> AREA TO NEAREST SQUARE FOOT: .
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) 1--, ErosionControl permit
<br /> BASEMENT: 1ST FLO R: ,
<br /> / iy JZ > , , TOTAL SQUARE FOOTAGE: , (slopes,disturbance, . -
<br /> gND FLOOR: 3RD FLOOR: ( fillip access
<br /> �'11�D ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ �> and available options.
<br /> (Please round to nearest dollar) $ / �, UUC.J
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Des ES() ['Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I Ito ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? �s ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? s ❑No
<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 to ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes [+]0o
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back)
<br /> 545-112(4/08)
<br />
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