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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 /> Alie,r/ct D s yn ,-comes LL C 0 Zoning Status;CUP; <br /> OWNER ADD S (Number,Street,City,Stat , ip) Deed Restriction;CSM <br /> 293-2 Huy /17M FA-111%1 G✓l -5-37i/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 40) N3 i 297is, k, 3 c' 2. r , n 0 okra tvothes, tam 0 Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AG NT NAME CONTRACTOR NAME <br /> y60) �-er- f jkrr- Pe s 10 Nor us 1 /(, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Z97-2 Mm 21-72 Nwy/nM <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> I-i kb/ WI 53+0 ff4tib W 5311 <br /> PHONE PHONE <br /> p Site Plan approval from <br /> (Q0 t) q.q - 2914 (0( --y 38-27740 applicable township. <br /> E-MAIL ADDRESS // � � f E-MAIL ADDRESS ` <br /> Y QV1 Q Q f 4 rTa 6 Mme. Gs 0 ( are ® 6.14V'Ya 1r10 PY1Q,s,Cori/ ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> EiPARCEL PARENT PARCEL�N UMBER: r� Q9 CU RENTZONIMG: ACREAGE: <br /> NUMBER `:J r c -,�'o f ^`F'?(l j7, a S frontage drawn to scale. <br /> TOWNSHIP: j _ SEC 10 : <br /> rn 1(�lX.�fl n '/4: i7e'/: s ❑Driveway permits <br /> ADDRESS: k/' '') �� h 1 i `t e (state,county,town) <br /> CSM: �// LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> ♦ (public,private) <br /> Chit Li t1A . <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DDjSC IPTION: <br /> 1- (7 6m C i rvf c� 01(n i it home. vv 1 j <br /> 'ft)r1 Q cc. ❑ 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 rAt EPTIC I 3- 2 ui a - 00211 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not inluding basement) ❑ Wetfland� ln/ <br /> 3 0 I Z Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionC.rxu►�+a <br /> BASEMENT 1ST FLOOR: <br /> I Ut[k 2 Q{lA + TOTAL SQUARE FOOTAGE j, (S�IO,pes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> r(12 8 ii ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --► ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) $ 5 1 5( 0 O b <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes Jo DOon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes Do QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Egres alo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? :Yes plo <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 alo ['Don't know <br /> 7. Is this to correct a violation? QYes glik10 <br /> APPLICATION MUST BE SIGNED <br /> 545-112 iaioe> <br /> �� (Continue on Back) -+ —► —► <br /> r- <br />