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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OyVER NAME _t- <br /> L c16` h-2r �t ❑Zoning Status;CUP; <br /> OWNER ADDRESS(Nubile(Street,City,Ste,zip) ,Q,Q Deed Restriction;CSM <br /> C� ? `p t 12 - Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL AI 1• SS <br /> cP t. a--' , • • ' ' i0 l' • •± ill I i.'0- I__I Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and indudes dimensions <br /> AGENT NAME \ I CO TOR NAME <br /> M L\ -e Cl JQJ fi I�1 I 1 -J ❑Site Plan including location <br /> AG ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (.040∎4 C CR_L O\Z C c�c. <br /> (city.St e,zp) cq, zp) w` El Setbacks <br /> L. Site Plan approval from <br /> lDU v- L H-3G j - -3E35' applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us)) <br /> PARENT PARCEL NUMBER: CLRBEW ZONING: AC ❑Elevation of property <br /> ❑PARCELR D N Z—"I+3-9 ZI C -4 -A <br /> \ 2 a 5 frontage drawn to scale. <br /> TO riiA.1'AfiNNO.Ir 10.--' CnON <br /> o t J%/•: "iz %��4. ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> a4264) .tC o 'j L U . ( r tb f t 635-23 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLO OT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJEQT DESCRI ON: <br /> ��( ❑ Zoning District <br /> . In is project is a new building or structure. ❑ Permftted Use? <br /> • is project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural <br /> .„Adckess <br /> [EWER DEPTIC (new ) <br /> HEIGHT IN FEET: ��` IuJ NUMBER F STORIES: (Not including basement) ❑ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionConhd t <br /> BASEMENT: 1ST FLOOR:Z(36 3et 4 TOTAL SQUARE FOOTAGE: j (slopes,distwbance, <br /> tilkngiaccess <br /> 2ND FLOOR: 3RD FLOOR: ) <br /> /Z F� ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: //11\\ and ay a options. <br /> (Please round to nearest dollar) ♦ ♦ -+ "'� ♦ ♦ Vv <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Eiglo Epon't know <br /> 2. Is there a wetland or floodplain on or near the property? es o �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? Res IO <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes Olo <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 2 o ElDon't know <br /> 7. Is this to correct a violation? ❑Yes ■ o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -♦ -► <br /> 545-112(4O8) <br />