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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 /> L owe,11 H C 1 ern rnonS Q Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> y Q I I Lot?sa4► 3t,Nch Pk d n1 c 1..4 , tvi S 3 55'8 Variance(# ) <br /> HOME PHONE ;CELL PHONE E-MAIL ADDRESS <br /> (OS'lig • q 61 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> V r-V{uv jt (\ cr,rn5 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Tai v5 RAJ y51 <br /> (City,Star Zip) (City,State,Zip) 0 Setbacks <br /> fflct'o►slarri , WS 55552 <br /> PHONE PHONE 0 Site Plan approval from <br /> Q.4 _ '7705 - ir$S? applicable township. <br /> E-A^AILADOR E-MAIL ADDRESS <br /> S V3,k), t1 IllaV,kCtiJ1Gt1L1'n5, 0 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 ObtO-O g`'{ •I"o' i frontage drawn to scale. <br /> TOWNSHIP: SECTIRN: <br /> -ro .)14 OF �JIIN `1 14: '> 1/41/4: 14 ii. ❑Driveway permits <br /> ADDRESS: ' y n(state,county,town) <br /> �-11-1 v 5 LOT�i���Qy 5!BDIVISION BLOCK/LOT 0 Sanitary permits <br /> CSM: (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> \400Q 40 u4 ❑ Zoning District <br /> This project is a new building or structure. CI 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 /> 1) ❑ Wetiand/Ftoodplain/ <br /> d� AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 50y <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -40, _� $ S�t��� and available options. <br /> �- <br /> (Please round to nearest dollar) $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [ Yes ao 00on't know <br /> 2. Is there a wetland or floodplain on or near the property? faes o �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes Llo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 152Yes Cto <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) QYes Rio DDon't know <br /> 7. Is this to correct a violation? IYes Elio <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ♦ -► <br /> 545-112(4ro8) <br />