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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> �p� CUSTOMER TO PROVIDE <br /> OWNER � x.,0 .„ lily 5 $)e_:4! <br /> lJ� ❑Zoning Status;CUP; <br /> owN R S (Number Street, State,Zip)) �J�i`/'� Deed Restriction; CSM <br /> HOME PHONE< %� CELL/�i�l / � E,!• LAD 'ESS C5S-c,6" Variance(# ) <br /> 4•-d Q � �''- � `v � , 9 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONT OR NAME <br /> f!re ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD of well/septic <br /> 74 em,-(City,State,Zip) City, ip ❑Setbacks <br /> PHONE PHON !� q7 ❑Site Plan approval from _ ° <br /> '/(✓ applicable township. I <br /> E-MAILADDRESS E-MAIL••DRESS/ �e <br /> i•I ((� 1, t'r ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.cc.dane.wi.us/) <br /> PARENT PARCEL MB CURR TZ IN ACR ••= ❑Elevation of property <br /> ❑PARCEL me-7/17-8r500 a de ..r Ql frontage drawn to scale. <br /> NUMBER <br /> TOWN HIP: SECj�I p- <br /> yy O, ,y `a j41 1 l/4l/:) 7g ❑Driveway permits <br /> ADORES �j (state,county,town) <br /> ��� f ���( '��� ❑Sanitary permits <br /> CSM: n^ LOT / SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTI <br /> , <br /> �4!�f i� C ❑ 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: �J PERMIT NUMBER: Li Rural Address <br /> EWER 1EPTIC la (new/existing) <br /> HEIGHT IN FEET( 1(!i NUMBER OF 7RIES: <br /> (Not including basement) Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: /j/ Ming/access) <br /> 61 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: QQ //J/ and available options. <br /> (Please round to nearest dollar) "♦ -♦ -.► _, $ ''1: (, iq <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes igivo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Les Oslo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 1:1 es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/vart'eneeAse a t ) (leave b ank if none) <br /> 6. Is a location survey required? (see reverse) ( �-°^ / 4- ❑Yes 2, o ['Don't know <br /> 7. Is this to correct a violation? ❑Yes I' o <br /> AUG 2 4 2017 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545112(4/08) <br /> r ,;'rw r '4'N; r 1L`:'. ,' .LNE:`Ji•l'a.'•I'J <br />