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3(V <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> zero gC\ O∎ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 2408 A,mhe-c Rd IA-,A\ , NI VII_ 53562 Variance(# ) <br /> HOME PHONE CELL PHONE E-NJAILADDRES <br /> (6°8)917-0033 a brag arc\ev\CD•"`°"‘'L""‘ 1-1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG NT NAME /� _ CONTRACTOR NAME <br /> V cCr CA 111 Site Plan including location <br /> AG NT AD ESS L' ,/ CONTRACTOR ADDRESS of well/septic <br /> 6L50 C�(t$M- //1�tfiV/l <br /> (City,State,Zip) (Cit ,State,Zip) n Setbacks <br /> L l.e ) 1 s <br /> PHONE PHONE Li Site Plan approval from <br /> .015 - t7 77-- e j applicable township. <br /> E-MAI ADDRESS E-MAIL ADDRESS <br /> • , 'Ci a'ic{t ` ar ❑ 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 p frontage drawn to scale. <br /> NUMBER 07 08—30t-8050 --0 At - 1 2 <br /> TOWNSHIP SECTION: <br /> 70■ r\ S I`A:Mke-4-or' 3b 1/4: Nt. +/41/4: \.1L ❑ Driveway permits <br /> ADDRESS: (state, county, town) <br /> 7 685 W M:,nera.\ ?b,,nly n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 1g' c \o01 c\00e\loukSe, ❑ Zoning District <br /> . NiThis 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 `I EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 ❑ 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: 1ST FLOOR: 2 <br /> ❑ ErosionControl permit <br /> \L,Q 0 . 4, TOTAL SQUARE FOOTAGE: 4, (slopes, disturbance, <br /> r filling/access) <br /> 2ND FLOOR 3RD FLOOR: ' 400 k\k 2 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ $ and available options. <br /> (Please round to nearest dollar) $ \ p 800 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? nYes ao fDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a o nDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? [7Yes 0 o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ❑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 ❑No nDon't know <br /> 7. Is this to correct a violation? ElYes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -+ -+ <br /> 545-112(4/08) <br />