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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 /> R0‘." - ‘K`‘i-}'"\ ID Zoning Status;CUP; <br /> OWNER ADDRESSJ(Number,Street,City,State,Zip) <br /> -3 ci 0 S- Ockk pc,,-.k R c,c-i`A Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS \ <br /> (•,KISS, 2�3�, ►�j",rtea►®► s��YlorviACVL -Wi ""S <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> l co,'v L `<`"e -- OSe_p \ S C‘Ni'CCl< ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRES N of well/septic <br /> (City,State,Zip) ( LA 4 -S CA- <br /> LA Ra P <br /> Ci ,State,Zip) ❑Setbacks <br /> v•-.bc: a, L51- <br /> PHONE PHONE 1:1 Site Plan approval from <br /> N.A. A %h, i s 'N applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> N A ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL MBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER O�4 O71Z.-2o-L��'3L0-�j �E}-Z �-q g <br /> TOWNSHIP: SECTION: <br /> Deer--1: tl d �0 '/: /UW IRA: p i j ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3Ck©5- ©Qk Pc.,r) Rocs C\ ❑Sanitary permits <br /> CD:q / g y LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED'PROJECT INFORMATION - STAFF <br /> PROJECT DESCRIPTION: //11 <br /> C ti-•n e C tad CD G•('d‘q ❑ 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 /> EWER EPTIC (new/existing) <br /> HEIGHT IN FEET: . NUMBER OF STORIES: (Not including basement) <br /> ev.v.7- `a ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached i garages and above grade decks or porches) <br /> ❑ ErostonControl permit <br /> BASEMENT 1ST FLOOR: 1,0 P <br /> ..: TOTAL SQUARE FOOTAGE: S <br /> �j(� �.<�_,;,,, j j - ( bpes,disturbance, <br /> "' fillinghaccess)_ , <br /> 2ND FLOOR: 3RD FLOOR: w <br /> N Pi /1/A ' ; B 0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ 2 ) C and available options. <br /> Please round to nearest dollar t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [ENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes R. ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes WIN() <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#16 yO ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) :Yes Jo ❑Don't know <br /> 7. Is this to correct a violation? :Yes 'lo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 taioe> (Continue on Back) ■ -+ <br />