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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME i <br /> D 1 11.. r .. . te l ...__._ V fl.l ........_....._................_. 'J Zoning Status; CUP; <br /> �,O'vVNERAQD S (Number,Street Ci y,state�ipj Deed Restriction; CSM <br /> '1,5 t L 00,K Lqn� — Variance(# ) <br /> HOME HONE CELL PHONE iE-MAIL ADD-ESS <br /> 110`47:3 (Pd 'Mail 1. 1.t1 ' i, f ,ItAJO II, CO(V" " 1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> SC.'Me (tS 11 po r- ,S i rA e aS -Lai/G 1 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) S• etbacks <br /> — — — — <br /> PHONE i PHONE S• ite Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS I E-MAIL ADDRESS <br /> N❑ F• loor plans to scale <br /> • <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.tlane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER-1, y /_ I CURRENT ZONING ACREAGE: p p y <br /> ❑ NUMBER 10 1(0 3oLL_/,3 1ST, R / _ �_ ,__/ •ntage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> l nc 50(k 1 30 <br /> -1/4: SG 1/41/4: s Driveway permits <br /> state,county,town) <br /> ADDRESS: ( <br /> 1 s� I et 1-t‘we e - —__— Sanitary permits <br /> CSM: LOT _ SUB•VISION BLOCK!LOT� blic, rivate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCV IPTI N: <br /> e^ t&c \e dGGK ;>oi e <br /> 4- sc.(Yv.i`e,\_ J Zoning District <br /> . aThis project is a new building or structure. NEI P• ermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> — P <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> — — . ❑ Rural Address p a, <br /> C4-6EWER <br /> _l SEPTIC (new/existing) <br /> HEIGHT IN FEET ,.J ( NUMBER OFISTORIES. (Not including basement) <br /> i Li 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 /> ❑ ErosionControl permit <br /> BASEMENT 1ST FLOOR: 4 <br /> 1- 0ry 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, %aim <br /> (0 11 filling/access) <br /> 2ND FLOOR: 3RD FLOOR: 6 d <br /> r0 ' ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ $ /�//�� a and available options. <br /> (Please round to nearest dollar) 'P SWlit <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1,14No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ly�Yes ❑No ?errnt-- i) <br /> reo "e J <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes W No U <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 1-Don't know <br /> 7. Is this to correct a violation? ❑Yes ULNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 545112(4'08) <br />