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1(tiSUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> J k(1 e- 0 Ke V, 0 / 1 G '^61 f ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Li 2 q(. 0/d Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRES <br /> ..2..33 -r(00 3 I+ C. r+-k6Irc/(,••CO,- ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> --1--;,,, S lt+ ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> 0 & - S-1 c -'-Z., d 1 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ' '/4: '/4'/4: ❑ Driveway permits <br /> ADDRESS: �� r^' (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: e p/.G'n� c icI Clec K M 4'k.i et <br /> 1 c u�1nc -G O�r,�< - r e rnh v,.� l,'X-( •�or 1, K� - lvo S UC-`ti,i� ❑ Zoning District <br /> . ❑This project is a new building or structure. Cha <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER E)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> I (�'^ 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 'f-5'' ! ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> (Please round to nearest dollar) --10. -+ -0 -. --► --► .6 000/ � cry <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Res ❑No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? (a k- Q- es ENO ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes EJNo <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) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? Des No <br /> t,f.. -.. (Continue Back) -0 SIGNED <br /> (Continue on Back) � � <br /> 545-112(4108) <br /> / 'C'''''S 0 . 42-77E ,ZG <br />