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ZONING PERMIT APPLICATION www.countyofdiine.com - <br /> / <br /> PROPERTY OWNER INFORMATION CU ` OMER TO PROVIDE <br /> OWNER NAME ``\\ 1� <br /> K p t2 p N`v ' ` 1 S A im Zoning Status; CUP; <br /> OWNER ADDR (N ber re City,St ip) / � ; ed Restriction; CSM <br /> � c ‘ k V �Q`A �®� ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6o8-2OQ 5 3 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes ' ensions <br /> AGENT NAME CONTRACTOR NAME <br /> N6eL fix re-e-5 0 to P n including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f ell/septic <br /> HAS PrZ (Z-oS L LIB <br /> (aty,State,Mz�)O�V� ' �l S �,� (city,State,Zip) Setbacks <br /> PHONE PHONE ❑Si Plan royal from <br /> 60k_ 39.C-3081 a plic a township. <br /> E-MAIL ADD'ESS E-MAIL ADDRESS <br /> :A , ltrYeStG Aq• • I F oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of pro pert <br /> PARENT PARCEL NUMBER: CURRENT ZON G: ACREAGE p P <br /> ❑PARCEL Z(„ ri 11W ,EN f ,c ,� I ) 0 frontage drawn scale. <br /> NUMBER `',' s., <br /> TOWNSHIP: SECTION: [� ,,I �-- <br /> s 17(lf N 6 D e\ L� z7 1/4: ��V\ I 1//1/4: dV F ❑ Drive permits <br /> ADDRESS: �/ V (st e, county,town) <br /> ND AI* *f/Li ZoC O <br /> 3 f j Wffe s$D � � �08"CB /V oM5(11M 4Sitary .- mits <br /> CSM: cY o ' SUBDIVISION o <br /> (publi , private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C, `.4l /L' r( t V ming District <br /> ❑This project is a new building or structure. Permitted Use? <br /> This project is an addition/ Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: , - ❑ Rural Addr s <br /> FIEWER EPTIC (new/ . ting) <br /> HEIGHT IN FEET: /0 NUMBER OF STORIES:IES: (Not including basement) <br /> ❑ Wetland/FI plain/ <br /> Shore d (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: ❑ ErosionC rol permit <br /> 4, TOTAL SQUARE FOOTAGE: j (slope ,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: �� fIIII /access) <br /> ❑ Review Location Survey, b <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q� and available options. <br /> (Please round to nearest dollar) $ i N© <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 Ro ❑Don't know <br /> ❑3. Have you talked with the township about your project and are they in agreement? Yes <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave lank' none) <br /> 6. Is a location survey required? (see reverse) ❑Y s o ['Don't know <br /> 7. Is this to correct a violation? es No <br /> ;r APPLICATION MUST BE SIGNED <br /> it <br /> ^ 545-112(4/08) (Continue on Back) ♦ ♦ ♦ , <br /> t <br />