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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Alin;4 V �V`iZ✓I ®/ C Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> k D� (/tr,G1 �'L 5./5.12-- <br /> /5.1 L Deed Restriction, CSM <br /> 3 3-7 I Sup�</.t 4'' t`� V Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> X Q P/3-5411' El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME t CONTRACTOR NAME <br /> A ii,! ,,,4ii ' d d( H i'}t lc cis y SA. - E Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS - of well/septic <br /> ?6 ti,,(' 4 g7i PO yri, _ ___ <br /> (City,State,Zip) (City,State,Zip) ElSetbacks <br /> tit h+L+i C "�f 1_39 94 Mel tL'�� ❑ Site Plan approval from <br /> PHONE PHONE <br /> ((,cs—Y 3-.mq g 6n,,J, r.Qs-476 3'-30 9'(1 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r il ae-cjC I a w) loco-Gt wn ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NU BER 03,Vo-tofe--'Z.tD-.Z 1y -•U R`0 ° . go frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> i i(id 1.,.,ft;n 2.1 1/a: we 1/a: ; ai ❑ Driveway permits <br /> ADDRESS: (state, county, town) <br /> 35'71544/14104k Pe Ve.eilq W.r.,�355 1L ❑ Sanitary permits <br /> CSM: LOT i 14 SUBDIVISION BLOCK/LOT (public, private) <br /> It/kilk. r11w1)farm <br /> PROPOSED PROJECT INFORMATION <br /> rA0.FYIIii'VI'iIN`Y <br /> PROJECT DESCRIPTION: <br /> !c' x 961 ' 4 ' !,,J. �'C 1 'Ai 1/41 CI Ch. r CVS'✓ Zoning District <br /> This project is a new building or structure. J Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> EWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> U Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) - <br /> BASEMENT 1ST FLOOR: (,...1 ErosionContral permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> g6 sJ. . <br /> �t_00 ij Revi: , o 'Mk ioStrvey <br /> ESTIMATED CONSTRUCTION COST: ...4 -� ♦ i ..4, $ — .71}c�7 and av +�• S. <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 ❑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? ❑Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies ao <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 riNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes [TNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -0- -+ -► <br /> REV(01/19) <br />