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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 /> �'PIA( .1e-C 6L.1:>(s• Tir , L L; ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 34 S LL-1 LL'Ac`Sa1/4-1,v€,v-t- '-cl= A-�t,o 1f , V l J 310 -3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS I <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> R,tA.N c I �, I tit C-- • R'-t L\ti S t(_->N ) WC_C - ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> ,, ti 1S„ Lit S31 i3 ILAav)( S,� Iv Le 1 S31I3 <br /> PHONE PHONE ' ❑Site Plan approval from <br /> -71 - 1119 ;, l k- -lot -I c', applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> h-, . vo,..--,;■' S1-{Evz-CY �-,,5, �`. ----k - S4. -IC • Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER OSA1 070,1 -3b3 -gls1,-e C' -- <br /> TOWNSHIP: SECTION: <br /> i., )i 7 1/4: %IA: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S 1411.1 Foe- -t-�./■,&N.;-r- K 41 •=1 - 2L-i ❑ Zoning District <br /> . ['This 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 /> IV' WER [EPTIC (new/existing) <br /> HEIGHT IN FE T: , NUMBER OF STORIES: (Not including basement) <br /> ❑ 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) <br /> BASEMENT: 1ST FLOOR: I—, ErosionControl permit <br /> 0 ,, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: v N 2-0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -1. -1). --1. and available options. <br /> (Please round to nearest dollar) $ 1 I<'Do tti <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ®Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑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) Eves ENO ['Don't know <br /> 7. Is this to correct a violation? ['Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4108) <br />