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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App s <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER ME <br /> r0bE{-1— I>12--1 azc<ning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, ip) r/(.''- ■-16,x-,�,rlj Deed Restriction; CSM <br /> qC/ 9 8/1-1 77 V ' y / IA 1 53.5-17— Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS L 044 <br /> (Jo(2-I q 92-0 c obe✓i-,ct/- .i, ..,,,,,co,R 6IN� P Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> M/\)t fAA''r- C1)-4 S F 0.-816-Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> r"-7 L+vv 1 (A._ <br /> (City,State,Zip) (City,State,Zip) lasabacks <br /> PHONE V VJ 1 lj 3 sq.3 <br /> PHONE Ite Plan approval from <br /> l DG applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> -- etor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> DPARCEL <br /> NUMBER V ']-0751-15T-1)- — -3 15, Li frontage drawn to scale. <br /> TOWNSHIP: SECTION: �� <br /> e,(` M 1O S Q '/a: ,,(� 1/a'/a: Sf CI Sriveway permits <br /> ADDRESS: (state,county,town) <br /> '° / i -iT ✓' t 4 M- �ir aJ 53 S Z L <br /> Y 0 Sanitary permits/ <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT <br /> DESCRIPTION: <br /> l�✓i-✓'✓i-e--F 'J Zoning District <br /> 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: ural A (ess <br /> ( <br /> EWER EPTIC (new/e Istl g) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> / 5 I la- detland/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: 1ST FLOOR: <br /> fj �,ErosionControl permit <br /> /° . c 1 TOTAL SQUARE FOOTAGE: + (slopes, disturbance, <br /> L filling/access) <br /> 2ND FLOOR: LOG : �I <br /> N( 3RD F IU f/'T �7 Se j-Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Gfl �,(/ <br /> (Please round to nearest dollar) ♦ ♦ -+ '♦ ♦ ♦ $ `00 D and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes fNo fDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? QYes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies 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) Efres QNo Don't know <br /> 7. Is this to correct a violation? LjYes fNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ - - <br /> 545-112(4/08) <br />