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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 /> A)V -P S`I A I /a�,1 Rd 'e5 ❑Zoning Status; CUP; <br /> NERAD RE S (Number,Street,City,etatee,//1�Zip) Deed Restriction; CSM <br /> 7 I1t 01.),. . 0w v', -t- /-_, el-, Variance(# ) <br /> HOME P�HOfNLf CELL PHO/N�Ei1 ILA>r RE.. <br /> 4Z'� `7 ► ` O (13q-111-14 �v t5 :s/ /Ox �� �`'^ n Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> T NAM: C NTRyA�C)T R NAME <br /> K--)A../ / , 1 Py f 11) ) 1 k lC e,Z n Site Plan including location <br /> AGENT ADDRESS ^' CONTRACTOR�/A�DDR S 1.... of well/septic <br /> 1 A �t4or,v.'2'_ Y" R o'I A (�''l�',i L)ly v C ....- /1.+ <br /> (City,State, )", (City,State,Zip) ❑ Setbacks <br /> /.._,,,A , bt.) I 5 'jS 4 ' CJ( . 7-3 5 <br /> PONE PHONE El Site Plan approval from <br /> C D c-, '1-'1 fr/^ PI j)2 (004 , ,(yW-`j 6Z- applicable township. <br /> AIL•DDRES E.• • •l eRE <br /> ( ��IL rid e.. 1l,S £ p r• c.�, n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) 11 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL `N/O 1 -i TI •2�^' �) ,._Z r frontage drawn to scale. <br /> NUMBER -T <br /> TOWN SECTION: <br /> JED Lk Q_ k ,/4. ,/4,/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 3o / tzg,1 L A - n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D CRIPT N: t 1 <br /> PC-1 Zyg -4-i1r,e /In w�K5 -a_ Y G1bK.. t„Q._ 5 ov+Iv •7(1e coning District <br /> . ❑This project is a new building or structure. afermitted Use? <br /> This project is an addition/alteration to an existing building or structure. �_, <br /> SANITARY SERVICE: PERMIT NUMBER: KUral Address <br /> EWER �EPTIC -, (new/ Isling)� <br /> HEIGHT IN FEET: lop NUMBER F STORIES: (Not including basement) <br /> Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, kached garages and above grade decks or porches) �—; <br /> BASEMENT: 1ST FLOOR: V CrosionCOntrol permit <br /> COO D 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2N-DC FLOOR 3RD 3RD FLOOR: I l/ filling/access) <br /> 70 "Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: {{ 43, and available options. <br /> (Please round to nearest dollar) '♦ —• ♦ $ j ,COZY y Z <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 No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es NNo <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 />