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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 /> "A-61A 'GL/ h//'/ Cj�1 Q Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City, e, i ) <br /> 5 -� `> .-- Deed Restriction; CSM <br /> /-,5 �/^wyf e,C�.// c-f7 d/'e 7e '- 4�� <br /> (/ / , � S S .S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADIORESS <br /> pn >-6 Z q 9 .3 7.5 - 76$ zei/i'- 11lcicce'lje, c Z - - ./czIcE1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5",47,-4 c_ [Site Plarding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well ti <br /> (City,State,Zip) (City,State,Zip) [rSSetbacks <br /> PHONE PHONE Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> EI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) evation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> NUMBER a/2/0 SO 2--e‘o Z -1/Z0-7 / ,'I frontage drawn to scale. <br /> TOWNSHIP: SECTION: '^�`l <br /> 6 /"`c (�c--- '/4: '/4'/4: 1 1 '-'riveway per <br /> ADDRESS: (state, county, .on) <br /> /S-S. 6;--'a- Qw/ c-/ ❑'Sanitary permits <br /> CSM: V LOT a„ BLOCK/LOT <br /> eom6cs. <br /> (public, Iva/�© <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: n n <br /> /hecs r lo c.14,004,7 .r"-k oe--- Loning District <br /> . ['This project is a new building or structure. ermitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Addr <br /> EWER (( EPTIC (new/ t n <br /> HEIGHT IN FEET: <br /> /3 (O �/ NUM OF STORIES: (Not including basement) �r' <br /> �, l_l W- .1• ...plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore an• =ttachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionCOntrol permit <br /> BASEMENT: 1ST FLOOR: <br /> 112 I 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: �,� <br /> J y 5f , f IJ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q� and available options. <br /> (Please round to nearest dollar) �V Q 000, <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 allo ❑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? ❑Yeslo <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 j5 o ['Don't know <br /> 7. Is this to correct a violation? [Yes 1 NNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />