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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 /> kI A 11-I ker 4' Ave S kooL loci � ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Numb r,Street,City,State,Zip) / I Deed Restriction; CSM <br /> 9- 1j v+ry' C, 141-ret I 6'O S cf 21 C' 5 WI 6.660gj Variance(# )%i HOME PHONE CELL PHONE E-M/ LADDRESS , <br /> b0'-1-g8 3 IV 6,ot -7-1-Ga5�, L%rdaLN.% )Icor ;ocli∎'com 2Site Plan drawn toscale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> 1 AGENT NAME CONTRACTOR NAME <br /> A 11i r &2,f4' _ _ IA Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS �, of well/septic <br /> -5/03 -T ih,.ic.-ST LE <br /> (City,State,Zip) (Cit State,Zip) ❑Setbacks <br /> (r0y5 PIA .1,...4 WI ‘ 5a� r-� <br /> PHONE PHONE i I�Site Plan approval from <br /> O C-_ g ,doZ- ' applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> [' 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 /> 11 PARCEL frontage drawn to scale. <br /> PARCEL b1O t' o13-62/( I' - I -- t D. L1 <br /> TOWNSHIP: SECTION: <br /> c* t�r65 f1S.h l '/4: '/a'/a: ❑Driveway permits <br /> ADDRESS: <br /> �/ pre„;,.,, i (state, county,town) <br /> g)la' Lt4 rr �a` Tv-01; ` cry4g w 1 �36. OZ ❑Sanitary permits <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT (public, private) <br /> I‘ aak , P t-5 ' p <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 2-00/- POI2 C44 At t t- ❑ 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 r)EPTIC (new/existing) <br /> HEIGHT IN FEET: I NUMBER OF STORIES: (Not including basement) <br /> i ❑ 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) <br /> BASEMENT: 1ST FLOO ❑ (slopes,disturbance, <br /> permit <br /> - - 11,..77".. <br /> ' v ,l TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> ,�•�■� filling/access) <br /> 2ND FLOOR: 3RD FLOO�R�. <br /> �v�/r."• 133 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) — — — ♦ ♦ 0 O C7 <br /> <; S c1.1 g> <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 'Jo <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 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> IN Lrb.-rt— .D t, ,..>crr 14.A./.6 S -r — e-• pro Y.4.1.r-.1 . <br /> N b P/2-e`Et O( PO re-`^ iT or-� <br /> APPLICATION(Continue MUST BE SIGNED <br /> �lc�E• (Continue on Back) -.. -• -► <br /> 545-112 14/08: <br /> fLPPL-tc.4".r- - Dc ,. _Sc r-E__ f L_- S sit— c-«.�,.,-r . <br /> Sv Zvi.-( c44 C1 IZvt� (cle,5 $"C czeiE,jL->ts <br />