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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME tt <br /> �A- ) / P .C�- -En - l4 By ❑Zoning Status CUP; <br /> OWNER ADORES (Number,Street City,State.Zip) Deed Re tr. ion;CSM <br /> 6.5 3/ n rza AW z)/441 411 ..6"& '21 Variance ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 603- ❑Site Plan drawn t Cale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes di ensions <br /> AGENT 4,U /11/6-1 -r CONT/11TOR NAME <br /> 6'19 f 1.3tic F; Site Plan ititrcing location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> g 6ac 492. n <br /> (City,State,Zip) (City.State,Zip) O M SetbS <br /> PHONE PHONE ❑Site PI �om <br /> 40e --2b'7-.2?.2 ' ;. , ,., appliG test hip. <br /> E-MAI DDRESS E-MAIL ADDRESS <br /> ' -) 1`�! biai Lt,1 r3.5, ", _.57'M AL, M:/ Floor plarVs t6 scale <br /> PROPERTY/LOCATION INFORMATION (http J/accessdane.co.dane.wLusl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 1 1 Elevation f operty <br /> ❑PARCEL 040;13 S 44460.5 r-/ ('' ) frontage dr n to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: s <br /> g.9 Y4: iV 1/41A: 5,6- ❑Driveway permits ( <br /> �t� `r' y�� ^' /� (state,county,town " <br /> ADDRESS. �7 /am1 - ,e/ 04,u6. air 5 ,Z ' <br /> j <br /> CSM: LOT SUBDIVISION BLOCK/LC ""°g,.._) 5p` <br /> k{, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ,� / �,i// <br /> Al E...'U) l -7 6= ❑ Zoning 3' rict <br /> . ❑This project is a new building or structure. ❑ Permittee Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMB : ❑ Rural Addr $ <br /> [EWER {EPTIC L.0 i 7�i t` i (new/e Stin <br /> HEIGHT IN FEET NUMBER ST RIES. (Not including basement) <br /> �©' �I `� j' ❑ Wetlan 1=t plain/ "� <br /> Shorela (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionCo.M f l permit <br /> BASEME N 1ST FLOOR: �� TOTAL SQUARE FOOTAGE: S (Slope; •i-., •-nce, <br /> C3-1 <br /> 2ND FLOOR: 3R0 FLOOR: ` �� filling/ e $) <br /> ❑ Review L•.F.t'. Survey <br /> ESTIMATED CONSTRUCTION COST: and-H-i - ;�e ••tions. <br /> (Please round to nearest dollar) �■ ♦ i -• ♦ $ 1 t ) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? :Yes a. ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dyes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes [ 10 <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 alo ❑Don't know <br /> 7. Is this to correct a violation? [Yes ato <br /> L Qjk•. APPLICATION MUST BE SIGNED <br /> 54si�z( ) t' - (R ' j3 L7LI3 YY ontinue on Back) -► - <br /> i <br />