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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME/ND&PENoic--✓i L,,✓,..rc / c - /e.,,✓M75or/ i 6 <br /> -414,2 6-' ✓,.•Ic eerA-""`_ OZoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> �7�� Cyr o 3 Deed Restriction;CSM <br /> '� It c 1-6 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> D C- n `l--2 PO ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -6 cJ c — , Dr Ir, L ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City.State,Zip) (City,State,Zip)� �/ Setbacks <br /> 0r4.Onr S3`7ii <br /> PHONE PHONE ❑Site Plan approval from <br /> 6 o $ - la 3v - 0// 3 (42 ,/, ,]E,vse) applicable township. <br /> E-MAIL ADDRESS EIAILADD SS <br /> 6eh. e./. a.e - C, sch.„„,ff cow ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑NUM ER ie 0� 302-0 I0 V© /' IGtd%Stn,. CjrJ� frontage drawn to scale. <br /> TOWNSHIP: E SECTION: <br /> C ire 0.c_ P�ctl.t 50 vt 3D 1/4: 1/41/: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> / 93 N " '' L'Q"', f �'"°1 S e. ^t 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> r <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: t _ I <br /> LWeAs" ,� 1 r — UP rd �b o itk L ❑ Zoning District <br /> OThis project is a new building or structure. <br /> 0 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 (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> /$—O ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ' ❑ ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access)0 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -■ , ♦ ♦ ♦ and available options. <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 I o 00on't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Jo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ao <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 'lo ['Don't know <br /> 7. Is this to correct a violation? ❑Yes Ets10 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) <br /> (Continue on Back) -4. -► -► <br />