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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER NAME <br /> . ¢ <br /> /q 1 k } C f/E U) h)T t1 [YZoning Status; CUP; <br /> OWNER ADDRESS (Number, reet,City,State,Zip) n Dped Restriction; CSM <br /> /15 /773 04Awovl chat r4A-1 ,, le o3677 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS i' <br /> P.- 93- :/7 /Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION rand includes dimensions <br /> AGENT NAME CONTRACTOR NAME - <br /> 8,C1i4 casohi l' RvdmI,Co, iWtW 3/6)j,,RpSvw01rrettpNCoksiii ' [Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> It?ox 775, f 4 7,3 Hwy /z a , ig3/10 f /4 <br /> (City,State,Zip) (City,State, p) [] <br /> Zip) Setbacks <br /> S'P&Of Cite41u (,vi 1/46--36.0e- spA, 16,Q.aev kii 6561, <br /> PHONE PHONE D Site Plan a oval from <br /> 6.0 8-- Sri- 710441 6 0 9 -- 3 cg r-a 0 75 I applica township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> NUMBER C1(?07-/gg30,4'Q R-1 ` T 7S <br /> frontage drawn to scale. <br /> TOWNSHIP: SECT.IO : r <br /> Ro 8U ,v I 1/4: 'J %xi: �� ❑ Driveway permits <br /> ADDRESS: LSR _ ( tate county,town) <br /> I �v Sanitary permits <br /> CSM: LOT f SU DIVISION BLOCK/LOT• 8 kKt/flWK F/ELOS (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ` - 1 <br /> 81 Ni e F4 m is Y Warn e_ J■J I C c t®'F') ? ) C c L oning District <br /> . This project is a new building or structure. Permitted,Use? <br /> DThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ ddress <br /> FIEWER ZEPTIC 13-2017 -00 A7 (new! xistIng) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/ plain! <br /> Shor nd (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages a d above grade decks or porches) <br /> BASEMENT 1 ST FLOOR: ❑ Erosion Con hermit <br /> Ai d v "-'A rrrO-3Y J ,, TOTAL SQUARE FOOTAGE: /(slopes, turbance, <br /> 2ND FLOOR: 3RD FLOOR: ! — �ll'n ) <br /> / Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -+ -+ $ and avails le options. <br /> (Please round to nearest dollar) 000� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies o Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies o Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Dies DNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Di DNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le a blank if none) <br /> 6. Is a location survey required? (see reverse) l 'es o ['Don't know <br /> 7. Is this to correct a violation? Dies No <br /> _s <br /> k- 3 f APPLICATION MUST BE SIGNED <br /> co (Continue on Back) ♦ ♦ -► <br /> 545-112(4/08) <br />