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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OWNER NAME I <br /> ��h V) �-- c5 d.1 q[ 1 p- 4 -zI e�j ! t=r ` a1, Zoning Status; CUP; <br /> OWNER AD DRESS (Number,Street,City,State,Zip) <br /> n eed Restriction; CSM <br /> .57Z V DtkiV r'! PO O P O -€ Ck1 5e . ,. ,s7 5" ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADE11RESS <br /> 606- $35Ey0 ' to a _3 35- ` "' < Z 5' ( A'L , C, Pi Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION n includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> _5,e_/ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Site Plan pproval from <br /> applica a to hip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> n F oor p ns to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) e Elevation of ro <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p <br /> 0 PARCEL //�� ��yy 2/1 p /� frontage draw scale. <br /> NUMBER O$1. )7 "F230-5' i-- L - / .l/ <br /> TOWNSHIP: SECT • ,� 1 <br /> rL1-�-luviL 7 '/a: YVV3/a'/a: AjF. ❑ Drivewa ermits <br /> ADDR SS: (stat , county,town) <br /> i) 10,5-L I, / — El Sanitary ."- mits <br /> CSM: �� ' LOT SUBDIVISION BLOCK/LOT (p •II , .rivate) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: / 4 l// ( K FO <br /> 6 01 - o oning District <br /> . ['This project is a new building or structure. Permitted Use? <br /> This project is an addition/ teration to an existing building or structure. <br /> Y ❑ Rural r s <br /> SANITARY SERVICE: PERMIT NUMBER: /, Q <br /> FIEWER EPTIC ' v ��J`f f (new Xlstln <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /6,'I �-/ ( ❑ Wetland/FI dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorel (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: I—, ErosionCOn permit <br /> l ' 0 j TOTAL SQUARE FOOTAGE: 4, (slopes Sturbance, <br /> filli access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1 l a 0 ( L <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) , "(,Q U <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves EINo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies EINo ['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 ❑N <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank. none) <br /> 6. Is a location survey required? (see reverse) Dyes o EDon't know <br /> 7. Is this to correct a violation? [ [Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i <br /> 545-112(4/08) <br />