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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> OWNER NAME <br /> Ake 7;4411 h 5 " V Zo ing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) /') D ed Restriction; CSM <br /> (015o fl,b v A d r5F' "Qci V lance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Oa?005 -' ❑ <br /> Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAM I ► CONTRACTOR NAME <br /> (n.�wKtrn b ( 47/6/ Zit.a.9,e Site Plan including location <br /> AGENTAD�ZESS CONTRACTO'g ADDRESS of well/septic <br /> sG/y Penhwk/7 574 <br /> (City,State,Zip) (City,S Ke,Zip) / �� 7 `/ Setbacks <br /> 114 <br /> PHONE PHON _ El Site Plan ap val from <br /> A�j� -2 - —02 3 5 plicabl ownship. <br /> E-MAILADDRESS E-MAIL ADDRESS! <br /> I't►», A. i�1. loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation of prope PARCEL <br /> PARENT❑NUMBER PARCEL <br /> p /!�s NUMBER: CURRENT CU(RENT ZONING: ACREAGE: Y� frontage drawn scale. <br /> TOWNSHIP: SECTIO • <br /> 7:w^ o /'/,T 1/4: NI 1/41/4: El Drivewa ermits <br /> !� Q (stat ount •wn) <br /> ADDRESS: `� /� <br /> /- S° t4hb )ess-Qr? Ore- -0-1,1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT El Sanita .ermits <br /> tut fi o 3 n—e1 ,/(/ p bl. , private) <br /> PROPOSED PROJECT INFORMATION K !� -TAFF REVIEW <br /> PROJECT DESCRIPTION: ( <br /> clt� wf/X /2 et.ry'ia-/ reiof Co 7 Z R •ningDistrict <br /> . <br /> This project is a new building or structure. ❑ Permitted s ? <br /> iOrhis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural A dress <br /> EWER litrEPTIC (new/e 'an <br /> HEIGHT IN F ET: / ? NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/FI••.pia' I <br /> AREA TO NEAREST SQUARE FOOT: Shorela•• (a hment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: t ❑ Erosion trol permit <br /> 1 TOTAL SQUARE FOOTAGE: ,4, (slope disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ((( c, 6 c Min ocesS) <br /> ❑ Review Location Survey I <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ��3�' `'V and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes ao ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres ❑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 revers ) Dies ENo /Don't know <br /> ❑ <br /> 7. Is this to correct a violation? Yes �/No �" <br /> APPLICATION MUST BE SIGNED 9 (..... c_o o <br /> (Continue on Back) <br /> 545-112(4/08) <br />