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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O-WNN�E�RnNAMEI <br /> TOM` C C%` ke, VIA'cs V ❑Zoning Status;CUP; <br /> OWNERADDRRSS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> '��'�j 1 Variance(# ) <br /> HOME PHONE CELL PHONE �E-MAIL ADDRESS <br /> ✓ 7 70 i9. 9 rcreite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT N E I CONTRACTO NAME <br /> 10 I N 10(2-;CA g c .'i14 aht,o ra,, Ref\ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o ell/septic <br /> /44.64A 0�0 r-re r y c <br /> (City,State,Zi ) (City,State.Zip) Setbacks <br /> atm �0wc w1 53T2 <br /> ❑Site Plan approval from <br /> /, <br /> PHONE V 1 2. P1 2-- PHONE applicable township. <br /> E-MAIL A� RE'S-�Sy` E-MAIL ADDRESS <br /> toll- e �1�1 �,(� Lam/✓) Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: 9�j CURRENT ACREAGE: in Elevation of property <br /> ❑NUMBER C VZ— 34Z /v / A I t frontage drawn to scale. <br /> TOWNSHIP: SECTION: l]►/ 3,(_ ❑Driveway permits <br /> C•�R l 'iA ��4' '" ��4��°' �f (state,county,town) <br /> ADDRESS: <br /> l[4t1 1'3 6644/1812-'1061 1 w t 5 3 5Z3 ErSanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 1 <br /> &I A-P-AC1 s✓ G 5600-(90A& A OO 0T100 ❑ Zoning District aY <br /> . ❑This project is a new building or structure. ❑ Permitted Use? yEs <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address 1. 11.4t, <br /> DEWER [EPTIC ' g6 - t'eo (new/existing) �_` <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) 1I tAp) <br /> 2� ' ❑ 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: 1 ST FLOOR, ❑ ErosionControl permit <br /> i.Z0© ,, TOTAL SQUARE FOOTAGE: ,` (slopes,disturbance, <br /> 1 �� filling/access) <br /> 2ND FLO q 4�� 3RD FLOOR: <br /> 22 c ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ d� �a and available options. <br /> (Please round to nearest dollar) �P <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes givo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ['Don't know <br /> ® <br /> 3. Have you talked with the township about your project and are they in agreement? Yes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes "lo <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 dlo ODon't know <br /> 7. Is this to correct a violation? :Yes ao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -♦ <br /> 545-112(4/08) <br />