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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNgli NAME .- <br /> ew se' ""i w 1- rt SN`. -e/ <br /> 4c--- Wing Status; CUP; \do <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restric n. CSM ` <br /> 0/165 14 t kat Iw6t4 Variance(# ( ) <br /> HOME PHONE CE 1_L PHONE E-M IL ADDRESS <br /> I.i 3 ' /4 0 -)24)- FiV (C - ._Ap • r S. Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFOIMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> oiGYL :8imA): PI cluding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS��� Of I/septic <br /> ( ,State,Zip) (City,State,Zip) Setb K� <br /> PHONE PHONE S' Ian app�eval from <br /> applicable township. 4 1, <br /> E-MAIL ADDRESS E-MAIL ADDRESS il <br /> r plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: �/(� CURRENT ZONING: ACREAGE: evatlon of property <br /> ❑ <br /> NUMBER <br /> 0(cc-.CO2� 073/�1 I"► 1 // 0 I 0•q frontage drawn to scale. <br /> J TOWNSHIP <br /> ( ,�„/� SECT: ,/4: ,/4,/4: n Drive rmits <br /> ADDRESS: P`v ( , c nty,town) <br /> a/44,5 o - Hat, Ret 0 S tary . -rmits <br /> CSM: LOT V I / SUBDIVISION BLOCK/LOT <br /> di (publ •rivate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE DES RIPTION: <br /> 0 4 Q Wing District <br /> . This project is a new b ilding or structur . P fitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: Rural `•• ess <br /> .,jr- <br /> EWEREPTIC h/�� (new/- Isting) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) Wetland/Floodplain/ 0 <br /> I to I PERMIT NUMBER: <br /> i' <br /> I� <br /> Shoreland (attachmenQ <br /> AREA TO NEAREST SQUARE FOOT: `G <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r 1. <br /> BASEMENT: 1STFL0 Erosio •nf • •ermit J <br /> O O j TOTALSQUAREFOOTAGE: y (SIO•'-, •IS . bance, <br /> 2ND FLOOR: 3RD FLOOR: fllling/a CeSS) <br /> /2a0 Revi Ion urvey <br /> ESTIMATED CONSTRUCTION COST: $ C J S )� and avail bl 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? Elves NEJNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? g es ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 0 es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 ea s? Elves "Jo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# i 6 "(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 />