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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION OFFICE USE 0 <br /> OWNER NAME //�� p e <br /> klit ken df14Ca11 B-q' p/ 4 Vo ,,Y L /7/•u4a1 ",(�.,j Zoning District <br /> OWNER ADDRESS (Number,Street,City,State,Zip) /z <br /> 50'0 44://g, Awn P. /f/ootf 64,7q il"Z 51//f <br /> Permitte Use? r PHONE E-MAI L ADDRESS <br /> 60e- 767- , ooO ❑ Zoning Status;CUP; �'Q r a f G <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restriction;CSM v9s3 <br /> AGENT NAME CONTRACTOR NAME <br /> Variance(# r <br /> AGENT ADDRESS CONTRACTOR ADDRESS V. <br /> X Site Plan drawn to scale <br /> and includes dimensions <br /> (City,State,Zip) (City,State,Zip) <br /> Site;;4 .ingllocationrr <br /> PHONE PHONE <br /> • septic <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> %Setbacks <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) A A► Site PI proval fm <br /> PARENT PARCEL NUMBER: ZONING: ACREAGE: <br /> ❑ NUMBER L/RO •?) -3 -WO 3 R`•-3 /2.6' icabletownship. <br /> TOWNSHIP: Q G 1 S TI l Rural A• s A_ <br /> //1/4 C. farm '/4: �� '/<'/4: N �V (new .) <br /> ADDRESS: e <br /> S4SO M�V4r arm 41 1144 Evrf' WI fj.S/s KFloor plans to scale <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ❑ Elevation of property <br /> PROPOSED PROJECT INFORMATION frontage drawn to scale. <br /> PROJECT DESCRIPTION: <br /> li X 5-6 64r4Je /510, permits <br /> . 53 This project is a new building or structure. <br /> )(Driveway <br /> state,county,town) /4- <br /> P J 9 1V <br /> ❑This project is an addition/alteration to an existing building or structure. Sanitary • <br /> SANITARY SERVICE: PERMIT NUMBER: (publi P <br /> ❑SEWER SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) 4 <br /> 23 I % J etland/Floodplain/ 4 <br /> .horelan k -a- - <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks ErosionControl permit <br /> BASEMENT. 1ST FLOOR: 3 (slopes,disturbance, <br /> `a%t 7JS V 1 + TOTAL SQUARE FOOT•GE: + \ P <br /> 2ND FLOOR: 3RD FLOOR:`'� ,V <br /> filling/access) <br /> �_ �4 Review Location Survey Ai <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦a�� .nd available options. <br /> (Please round to nearest dollar) 33 395 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes X No ❑Don't know <br /> 2. There is a wetland or floodplain on or near the property? ❑Yes 20 No ❑Don't know <br /> 3. Have you talked with the township about your project? 4 Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 51 No ad/a r,/k nv ed y e <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? ❑Yes jNo ❑Don't know <br /> 7. Is this correcting a violation? Cl Yes • I No <br /> APPLICATION MUST BE SIGNED(Ct S <br /> 545-112(1 08) 6 ySL:c (Continue on Back) -i -i ED <br />