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c t ,49,,.,;,,17 7r <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION • <br /> C CDO PROVIDE <br /> OWNER NAME <br /> IO 1 . #Iref-. AU( [� o S�tus;CUP; <br /> OWNS SS (Numbreet State,zip) �-+ De tPRestriction;CSM <br /> felt'7 /1 w7 /01 !✓a•,Ag eL will' jr:_ G/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS PANE Cry a„„ <br /> 6 (o.P°- YX�6-?Z'.- ...J I, 4 eke r" i s, '"141 /'Cr'wl"+.�►pLUE7ylu�e1 110 to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION �]and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Se/{'-JOAA iPc ,,,^ ❑Site Plan induding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> -rG f &7 / -y /0t <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> i.•d v..a/tee No is' f z's'92 <br /> PHONE PHONE ❑Site Plan approval from <br /> ‘.y- ci yr- C p2r- applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> f4"„, ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: , CURRENT ZONING: ACREAGE: <br /> ❑NUMBER RC OM 1- Acid / ,p frontage drawn to scale. <br /> TOWNSHIP: O 09,1-000 <br /> SP” SECTION:? 1/4: 1/,1/4: ❑Driveway permits <br /> ORES rJ� - (state,county,town) <br /> ADORES : <br /> fitt7 1•11v7/t— AI41.4.dil a K�z. Lk-c-t S-7-5-9/ ❑Sanitary permits <br /> CSM: LOT SUBDI N BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> La Lt■ . er 6Zrddn ,r// ❑ 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 /> FIEWER PEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not induding basement) <br /> i Ft- _V ^ ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FO Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErOSIOnCOntrol permit <br /> BASEMENT: 1ST FLOOR <br /> ` TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR <br /> °c /0 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ QQ and available options. <br /> (Please round to nearest dollar) ,p I QQ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Jlo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'es 4o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes tElrio <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 Elisio [ Don't know <br /> 7. Is this to correct a violation? ❑Yes El'10 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -► -► <br /> 545-112(4ro8) <br />