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ZONING PERMIT APPLICATION www.countyofdane.com Fr=1122221:11! <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> l� 0 Zoning Status; CUP; <br /> OW ERADD J(Numb r, treet,City,State,Zip) AL#_ q Deed Restriction; CSM <br /> �f yy9 14/&'i�'�1'ei-L,/ GU r • Variance(# ) <br /> HOME PHONE CELL PHONE -MAIL ADDRESS / <br /> %�4..-"a/ ,' / 7" /7 -,/� 3 / r 4t 11.5- ot ou 4 1•C�fi O Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGE T NAME CONTRACTOR NAME <br /> /4 j // /6/4; 5 +/ fit,0je(,�'�-�.67riies 0 Site Plan including location <br /> AGENTADDRESS ONTRACTO ADDRESS of well/septic <br /> -? 10- nlam 57L( 24` .77� , F rl, 2Z/16(Y- <br /> (City,State,Zip) (Ci State,Zi�p,)�� O Setbacks <br /> �'i rv /l�,j �r , 5359e o J �,( • 53,ep <br /> PHON,E / Site Plan <br /> approval from <br /> 617 ;7-- , g" iP6F-P -g,,yle applicable township. <br /> E-MAIL ADDRESE MAIL ADDRESS <br /> l / 1, i v '( ; j . at" 1 i/ // - I; d _ - • l/yf'P.S .lf t ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acce5sdane.co.ciane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL Q �j ( , _ frontage drawn to scale. <br /> NUMBER Ogli ' ZVi- "AO 1' I � �, g <br /> TOWNSHIP:nSECTION: <br /> f�J l7 kJ f 1e- '/a: /4: ❑Driveway permits <br /> ADDR ss:�J �i (state, county,town) <br /> 49 ! Nee' gad/ ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPT N: r <br /> aWe reV,iJ Pre <br /> i2 1 G troe4 7a <br /> AT) <br /> 0 Zoning District <br /> • its project is a new building or structure. <br /> ❑ Permitted Use? <br /> OThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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: ST FLOOR: ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: �r-� filling/access) <br /> �Z �`" ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ Q and available options. <br /> (Please round to nearest dollar) �p /G/i 00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? JYes ONo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes No EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Zfres No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Ryes ONo <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) aes ENo nDon't know <br /> 7. Is this to correct a violation? OYes No <br /> (' <br /> 0, 7,0 72 bO O3 <br /> Vii APPLICATION MUST BE SIGNED <br /> REV(01/19) /( (Continue on Back) —0- —► <br /> O \Y 1 <br />