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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 /> Par A �C 0L 1 uI 14(I ❑ Zoning Status;CUP; <br /> ESS Nunyer,SPee Ci tat , <br /> P {� �� f ,� Deed Restriction; CSM <br /> WinAZ .--licotiatc �• lei �l�V /�V ��.� 5�5� Variance(# ) <br /> .HAMEPHONE PA>- E/ CELL PHONE rn L6 J E-MAIL•D ESS p <br /> 6 .- ' 65 I .J 5 I■ eit=(-.I ( UIIali-h 1 I laj L«JU1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME <br /> QU CTO FJ1 do ❑ Site Plan including location <br /> AGENT ADDRESS o T of well/septic <br /> r r4 (ril.5fr l� <br /> (City,State,Zip) (Cit State, ip) ❑ Setbacks <br /> �rU��1 � WI ��j5zi <br /> PHONE PHOy r ❑ Site Plan approval from <br /> G/l(�f� 5-"76�5 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Gl . a ® ` , cc ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> ARENT PARCE NUMBER: CU"ENTZ NING: ACREAGE ❑ Elevation of property <br /> PARCEL 616�/1�,\7,./�I..(�6 _0 1- 112- `� frontage drawn to scale- <br /> NUMBER IJ.JIJ l � <br /> TOWNSHIP�-�_I I 1 1 Me. SECTION:1�1L..//II %4: ,/4/4: ❑ Driveway permits <br /> ADDRESS (state,county,town) <br /> 30o OId. 69 <br /> ❑ Sanitary p <br /> CSM vate) <br /> �/� I I LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 11eu, one ❑ Zoning District <br /> . ,his project is a new building or structure. <br /> ❑ Permitted Use <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PE NUM ❑ Rural Address <br /> ❑SEWER EPTIC f NUM2 7 -UC3�i (new/existing) <br /> HEIGHT IN FEET:z Z/ NUMBER,OFST STORIES: (Not including basement) <br /> 0II ❑ Wetland/Floodplain/ <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: ` Cl /i i 1ST •- ❑ ErosionControl permit <br /> Ilrll + TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR 0 filling/access) <br /> `ASS` <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ 2")_—/n t1I�(�(� and available options. <br /> (Please round to nearest dollar) I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,QNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Y No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes D rip <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes YJ No <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) ❑Yest (y ❑Don't-know <br /> 7. Is this to correct a violation? ❑Yes o • <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -9 -► -+ <br /> 545-112(4/09) <br /> i <br />