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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 /> 2- 2 oning Status; CUP; <br /> OWNER ADDRESS (Number,Street,Ci State,Zip) <br /> 339' - Deed Restriction; CSM <br /> I Variance(#•3 CA. r- ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> EUrrl,4°1 6--71 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> De o. . 1-Lc,^-_ ©e,..---itep--Q-s C,, -,,v.. ❑Site a ' cluding location <br /> AGENT ADDRESS ii CONTRACTOR ADDRESS O tiC.� <br /> I�T �1 0 4tl v ee _s-72- <br /> er- <br /> e,Zip) (City,State,Zip) Setbacksk 1/p„ <br /> PHONE PHONE El Sit- ' -n as• oval from <br /> cr)7 3 PIS a.: •-..0etownship. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> F plans o scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.us/) ation of property <br /> PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> 111 PARCEL vI ro frontage drawn to scale. <br /> NUMBER 06/0 -S3- 'fp-- / R 3 6 <br /> TOWj1TIP: SECTION: <br /> US/ 1S 1/4: S LJ 1/41/4: Ivewa mits �y <br /> ��� (state,c ty,town)`/) <br /> ADDS: q", <br /> 3 `teary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT .•• •rivate) <br /> PROPOSED PROJECT INFORMATION F REVIEW <br /> PROJECT DES RIIQfjl: pe <br /> Kam/ f iv eiy� Vo • Istria <br /> . <br /> This project is a new building or structure. ermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Address <br /> NEWER rEPTIC N (ne exis n• <br /> HEIGHT IN FEET: NUMBER OF ST RTES: (Not including basement).-. .3 A - -nd/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Sho = - attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) .1 rosionControl permit <br /> BASEMENT 1ST FLOOR: <br /> o 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: / 3RD FLOOR: T filling/ (mess) <br /> \ Sig ; eview Location Survey <br /> Y <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) •V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑No Do know <br /> 2. Is there a wetland or floodplain on or near the property? es fNo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Dies No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yeso <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 ❑No ['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(4/08) <br />