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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> MI CAI Qe.I 01 cur� I� ern p ? 9 Zoning Status;CUP; <br /> OWNER ADDRESS (Num�`Street, ity, Zip) , WSJ.5(�9 Deed Restriction;CSM <br /> 3/(Q � . ilCPJGtU,�e� S� �.� V1�`�, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADORESS <br /> le0S7- g1I-135J (P08-751- /71 - ," 4 5,i-)e makae et" 'CO")Vet" El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 9 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks <br /> PHONE PHONE 9 Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: 9 Elevation of property <br /> EiPARCEL 0 lP I o -35a 95/6 _ 0 R i-1 ., bc) frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: T SECTION: <br /> u ikhtN. '/+: '/.'/e: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> L al•c, Keg crass a, Rd . ( -7'S.5 <br /> ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> iii-_-__Li S / (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: C <br /> d%n C a_vYN I \`s o✓✓i e_ ❑ Zoning District <br /> - IgiThis project is a new building or structure. <br /> ❑ Permitted Use? <br /> QThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVI : PERMIT NUMBER: ❑ Rural Address <br /> EWER 1)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2Z/ 1 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) I—, ErosionControl permit <br /> BASEMENT: 1ST FLOOR:v V <br /> .3��� ��d j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: p 4 filling/access) <br /> 0 /'16 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ �(2 Q and available options. <br /> (Please round to nearest dollar) r <br /> 4 6-4,f. iD <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes [ lo 9Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes rj. o 00on't know <br /> 3. Have you talked with the township about your project and are they in agreement'? [ .Yes a o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Oyes [ lo <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) Oyes Dlo QDon't know <br /> 7. Is this to correct a violation? QYes alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -, <br /> 545.1121108) <br />