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1 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> t—O .JU 0 H C tern +riNoN ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> y VI l 1- -,on 32a.ch 94 eAc 1,1 , tvI S'5 S' variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (DOS- 11(1 - ti(5Y El Site Plan drawn to scale <br /> AGENT INFORMATION i CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> v ; cc uv i s{1 t'o,s-lin5 Q Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1"711 6 u5 I-kj y 51 <br /> (City,State,Zip) (City,State,Zip) Q Setbacks <br /> fflc1'-4'66 , J I 515S/ <br /> PHONE PHONE Q Site Plan approval from <br /> `lloa- �JS - r$S ? applicable township. <br /> E-MAIL ADDRE S {{' E-MAILADDRESS <br /> e- q�^ 1(i klckk t(xi\Lt(11S: Q Floor plans to scale <br /> ■ <br /> PROPERTY,'LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 0 Elevation of property <br /> 0 NUMBER OLCt0-C CM ' IOC C' 9 ( frontage drawn to scale. <br /> TOWNSHIP: _ SECTION: <br /> "-r-OLJO :: �J "1 '/4: ' thy4: i_ ❑Driveway permits <br /> ADDRESS: ' y (state,county,town) <br /> ail 17 v5 4+��w�� 51BDIVISION BLOCK/LOT <br /> CSM: LOT Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Roo? }IOJSe Zi-i f x ..7v ❑ 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 r_REPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> r I, ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: r---. <br /> ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 1 3RD FLOOR: <br /> \-2)(iti <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -4 -4. Q ©v v and available options. <br /> (Please round to nearest dollar) �P <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? afres Dio QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ®Yes alo QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? lyfres alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 5i1Yes laio <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) Efres Rio ['Don't know <br /> 7. Is this to correct a violation? [ Yes EINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ■ -► <br /> 545-112(4/08) <br />