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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 /> I-t' KA c. t `� of ❑Zoning Status;CUP; <br /> OWNER ADDR SS (Number, <br /> Street,City,State,Z■0> Deed Restriction; CSM <br /> 66 YO It r y (t, it 5 P rL .c i Ldt 53590 Variance(# <br /> ) <br /> HOME l CC PHONE E-MAIL <br /> ,06-ZcZ-934 ♦. 4. At me , • ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Pa.-1 31tket- 0sovxTcx .Lcw.clSwl(1xv.S ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3S1-0 Piat vcc.r (ZA 354-0 Pi ovvcc,r <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> J ov.s.. C L.1 5;S91 3 VC■rOtna i k.,,)l 53S9-3 <br /> PHONE PHONE ❑Site Plan approval from <br /> 607— .Z-4-9401 .t.c.. Iuj (dn- g24-91/41oI applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> � <br /> -� C3 d.5 + .ccm" 10---t f otso"-tc.ov. •Ccwx ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUPARCEL frontage drawn to scale. <br /> MBER OI Z/o (l-3o' —20$Z-O A.1- 0,64+ <br /> TOWNSHIP: SECTION: <br /> 6ri S4 t ?'o 1/4: '/4'/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 6,6-� 'afv./ Qya./. Tea•( . 1=1 Sanitary permits <br /> CSM: LO SUBDIVISION BLOCK/LOT <br /> 3Z. (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION. I ( I y,l ZOilln D. tri t <br /> (�5 1\ 1M yt,-)v4 5 t( SIId /(/iC4y1 ic'ucci00.4 w/ a. cWtl— g Di. <br /> . ❑This project is a new building or structure. I Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: lai Rural Ad± <br /> EWER �EPTIC /' ie� <br /> (new <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) l.d'_, <br /> Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ry'W <br /> BASEMENT: 1ST FLOOR: E rosionControl permit <br /> t� j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: , filling/aCC2SS) <br /> OD 0 l J Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ -► ♦ -► G 3/�,(o,oo <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes NNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Kies ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <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 ®No ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -+ <br /> 545-112(4/08) <br />