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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> CEP - 2de- 1, 't <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME L <br /> ❑ Zoning District <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> (e9© /titi4.C4 S hcy D <br /> \ ii,,, 6j1 S 39Z ) Li Permitted Use? <br /> PHONE E-MAIL ADDRESS <br /> hoe - gce 9— 40.p.3 7 °-- <br /> ❑ Zoning Status;CUP; <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restriction;CSM <br /> AGENT NAME CONTRACTOR NAME / Variance(# ) <br /> AGENT ADDRESS CONTRACTOR ADDRESS ❑ Site Plan drawn to scale <br /> 3c-'( e'er-'"-6', ',-x and includes dimensions <br /> (City,State,Zip) (City,State.Zip) _ <br /> r+"e`3`r�/ �_ 53s�� , 7 Site Plan including location <br /> PHONE HONE <br /> G -- 9ZY - Lt9—c of well/septic <br /> E-MAIL ADDRESS E-MAIL ADDRESS �Ott 4.. e c� >,.,..,/w <br /> .e7C ,. c.c;,,` ❑ Setbacks <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) LI Site Plan approval from <br /> PARENT NUMBER: ZONING: �} ACREAGE: applicable township. <br /> ( NUMBER 1769-29Z-Y —� (.H- Z 5, €. 7--- <br /> TOWNSHIP: SECTION: <br /> (/;. �vrA- '2-9 c ,/4: N, 1/04: toe-. ❑ Rural Address <br /> ADDRESS: (new/existing) <br /> L <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> plans to scale <br /> 1212 2 — <br /> ❑ Elevation of property <br /> PROPOSED PROJECT INFORMATION frontage drawn to scale. <br /> PROJECT DESCRIPTION: . <br /> 54..,14- — ate r <br /> (7 ° ❑ Driveway permits <br /> . ,This project is a new building or structure. (state,county,town) <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: $anitary permits <br /> j SEWER XPTIC C'' i 79 4-1 (public,private) <br /> HEIGHT IN FEET: j NUMBER OF STORIES:RIES: (Not including basement) ❑ 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) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: O <br /> /5/4/ Z.Z e> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR' Z 3RD FLOOR: �� filling/access) <br /> q56/ t/ <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ■ ♦ -► -► ♦ $ 27c C.dd and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? _.)Yes ❑No 1 Don't know <br /> 2. There is a wetland or floodplain on or near the property? Li Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project? Yes C.1 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ,[lo <br /> ) (leave blank if none) <br /> 5. This project is associated with a rezone/CUP/variance(petition/appeal# <br /> 6. Is a location survey required? ❑Yes No ❑Don't know <br /> 7. Is this correcting a violation? Li Yes No <br /> C-` &�; e. C. APPLICATION MUST BE SIGNED <br /> �,�{/�, (Continue on Back) -1 ■ -► <br /> 545-112(VW <br />