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ZONING PERMIT APPLICATION www.countyofdane.com 1 SUPPLEMENT to Web-App; <br /> ( <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME � t <br /> d U e7 tf /1 C_ . Ap) cc d: �__--_ b iz1 �112,5dN El Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 -- Q �2' )-r-69,0r) 50 P. Variance(# ) <br /> HOME PHONE CELL PHONE IE-MAIL ADDRESS Site Plan drawn to scale <br /> /`a '-144-1.5 R 31G *MM-24 -00 f` 0 CO �) Vt/i ,co +'�? 6 C and includes dimensions <br /> GENT INFORMATION CONTRACTOR INFORMATION <br /> AGENT NAME CONTRACTOR NAME <br /> 0 �o n lg 1 <br /> AG ENT ADDRESS v Core E Site Plan including location <br /> CONTRACTOR ADDRESS // of well/septic <br /> 1 c10 Noll si- r >°f� aye p00 ) , 5 i( '-e' <br /> (City,State,Zip — <br /> Setbacks <br /> V e`( U Y1 a t (4-/ 3 V-e (0 4 a 11)f 3 . Site Plan approval from <br /> PHONE _ PHONE /� <br /> 6o3 - 770 .rQ j� d 37 55 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS n Floor plans to scale <br /> Ve '0n0 4 C leo ( 1,9 t �',c ► m v��Dna clel bvl ,n 04 <br /> PROPERTY/LOCATION INFORMATION (http:Uaecessdane.co.dane.wi.usq n Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING' ACREAGE: frontage drawn to scale. <br /> ❑NUMBER 05 2/05)0--271.140oi-0 A--1 ( )0 <br /> TOWNSHIP: SECTION: Driveway permits <br /> fq (01 1 C 27_ -V 1/4: S.'' ,A,A, (state,county,town) <br /> ADDRESS: <br /> 143 L.GKe 4'e9onSa g t ISanitary permits <br /> CSSM' LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ❑ Zoning District <br /> This project is a new building or structure. ❑ Permitted Use? <br /> 0This project is an addition/alteration to an existing building or structure. __ ❑ Rura{Address <br /> SANITARY SERVICE: <br /> PERMIT NUMBER: Rural Address <br /> EWER �EPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) `] Wetland/F000dplain/ <br /> �— AREA TO NEAREST SQUARE FOOT: _� <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErosionControl permit <br /> ,- <br /> 1ST FLOOR: i TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> BASEMENT: 1ST ♦ filling/access) <br /> 3RD FLOOR: "7 /) 0 <br /> ZND FLOOR: t/ ❑ Review Location Survey <br /> 1 and available options. <br /> ESTIMATED CONSTRUCTION COST: ♦ .�► —► } 3 �1 / nOO,ctD <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 ��--,,/' <br /> feet of a stream or 1000 feet from a pond or lake? (l'eS LJ1VO ❑Don't know <br /> � rs �i No [Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Y <br /> 3. Have you talked with the township about your project and are they in agreement? Dees rjNo <br /> ? L_.1�es ° <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? <br /> (5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> Yrs ° ❑Don't know <br /> 6. Is a location survey required? (see reverse) uQY es <br /> 7. Is this to correct a violation? Ilego <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4108) <br />