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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 /> 0\1 v&S ro rLs /-SS Q C 1 A T b ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 610 CA-P-1)1 N R L LN i 5 VI T& 10 0 j HAP-FLAN D WI variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 530 251 <br /> • N • — 20• ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ` CONTRACTOR NAME <br /> 1004 L C pFiN E - n/C o M Fj CONS r uc oN ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 143LI c' AC S 2v clef FoV - Dia . 1fDZ <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> M►c1-1)lSoly /41 55+Dy MoicoN , V') I 51-IT <br /> PHONE PHONE ❑Site Plan approval from <br /> (t.Vb� '24 — yDg2 ((,O f 7 —5/2-0 applicable township. <br /> E-MAIL ADDRESS E-MAIL AD ESS •` i <br /> 1'�t�Co�,C @rt'v. Co bvi(dS.Corvi❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdane.co.dane.wl.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL Z5 110b10—2-4-t -l;o` -4 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/4: 1/1/4. ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 2323 C2-o55 tz-o A I)S D tz . <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> 4 5 y O (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> "ACM P b YL n-1- .1 C(L iot N ❑ 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: Li Rural Address <br /> EWER rEPTIC <br /> (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> VDU Shoreland Wetland/Floodptain/ <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 FLOOR: ❑ ErosionCOntrol permit <br /> 4, TOTAL SQUARE FOOTAGE: ,l (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -1. ♦ -. $ and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes roll o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es M' o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? es LINO <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 K,No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ —4 — <br /> 545-112(408, <br />