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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 /> DP. E S5€1Z E]Zoning Status;CUP; <br /> OWNER ADDR S (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> J ti H& N to i el 2- , IJ C c ,V14, X1.11 5.3S13 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (.o9_837_622Z GT E sSe/z. a Ta S. Act ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> lC(9, (3u�14(-. (Srnue AA+i-L) ,toi.)E Alt _coA>S?ievtTto4) LCL _ El Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ,('J3p2q 110- /We A)2ovq / (ti-AAR <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> MO.URo€, Got 5 3566 M 0,V(?gei w( S 1566 <br /> PHONE PHONE ❑Site Plan approval from <br /> 608- 32 5- 6eo o (.c4 -3 25 -6000 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> kNi• 57 ,mot c.CcaA)5T,c a"-"■_ . ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (h ttp://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: 1CURRENT ZONING: ACREAGE: <br /> ❑PARCEL _` frontage drawn to scale. <br /> NUMBER 016/0507-024 -8510-0 <br /> TOWNSHIP: SECTION: <br /> 2l AA eoJe 2-5.-7 1A: ///Gl) 1/41A. SC ❑Driveway permits <br /> ADDRE S: (state,county,town) <br /> t€1(14 Nw y 12 4/00 NR/ God 5 3513 ❑Sanitary permits <br /> CSM: OT SUBDIVISION BLOCK/LOT <br /> %28 ti 7 (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: . <br /> P eGO CIETra ie J — A 6 B u I t_o∎lU Co ❑ Zoning District <br /> . [ C]This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER PEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2 9 t ❑ Wetland/Floodplain/ <br /> et Goo Pr AREA TO NEAREST SQUARE FOOT: 'Too 1a Shoreland (attachment) <br /> (Outside dimensi ca <br /> ons including unfinished area,attached garages and above g ade decks or porches) <br /> BASEMENT: 1 ST FLOOR: 1--1 ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> q(0000 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ©p and available options. <br /> ♦ ♦ -0. -, ♦ <br /> (Please round to nearest dollar) Sq, 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Jlo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Ekes } Vo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'SYes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ®Yes ao <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) Ekes EINo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Jlo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ■ -► <br /> 545-112(4/08) <br />