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ZONING PERMIT APPLICATION www.countyofdane.com Er=1! <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> To a 'f" t7Nt 7E V`jA-f tY-- ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2-6 6LtT`) O- Gt e--CLA 60117 E dve', W 15 527 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> bag,iw.e e Z 4\ •,4ti9 .a I 6t✓NelAVJEA1 STh CO"A Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> N. C2ArVt 0 r Lt - i AyL/ - r.8.0. Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> `(-11 MA'S -1\i <br /> (City.State,Zip) (City,State,Zip) U Setbacks <br /> r-P41 , WI 07,- 2642. <br /> PHONE PHONE CI Site Plan approval from <br /> 262 6179- 1133 <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> pAJLO e W (7A-t o ,UEK,.CQAA ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) E-1 Elevation of property <br /> PARENT PARCEL NUMBER: y� CURRENT ZONING: ACREAGE: Eleva a drawn to scale. <br /> Z PARCEL NUMBER 0e-C,?'I I- i t 3'0"'j -D p--1 7d, 217 f f- g <br /> TOWNSHIP SECTION' �� Driveway permits <br /> ( . f'te>At ig■E 34 �' `� i "�4' (state,county,town) <br /> ADDRESS <br /> 22 6 L.erN "14, CV-Cl.E co jTAcook; ‘Al 15 3527 i,=] Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> 'fptj LOT �'� <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> NOA1 10-bt'DUM9 p00t-, 1°x!, { A,y)t( + G(Ml b WP+tt,5 ❑ Zoning District <br /> . J This project is a new building or structure. +1-14\105GAe/n1 b <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 /> SEWER EfSEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ��L tali r 1�,0,,) DOE (t _ ❑ Wetland/Ftoodplain/ <br /> l _ Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT 1ST FLOOR: disturt�ance, <br /> (PO n 9 I ( ) 1,i Wit,7 j, TOTAL SQUARE FOOTAGE: j (slopes, <br /> (� 1 f %`r`[ / p, rj�r({�li� filling/access) <br /> 2ND FLOOR t0 `✓F" MO rSEIwoP) -7 t37/ /�f�o '/r <br /> ( � %i �j�" I` ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -+ ♦ ♦ ♦ ♦ Q (�__, Z and available options. <br /> (Please round to nearest dollar) $ f�� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? J Yes ;J No Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 'Yes Li No Li Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? rLYes Li No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? L`/Yes J No Z <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) Li Yes 'No Li Don't know <br /> 7. Is this to correct a violation? !JYes 1ZNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -♦ —► <br /> 545-112(4108) <br />