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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> pp I
<br /> J61 h IA 4 P- 104,0 pry if w‹. - I 0 Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> -7,;?(e.. Restriction;64 ti, 64_,0,1 0 Q S ,'4.,, 4' e _ CV L. CSM
<br /> Variance )
<br /> HOME PHONE CELL PHONE ' E-MAIL ADDREYS '
<br /> ;' -Gw3 3o33 El Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGEAT NAMECONTRACTOR NAME
<br /> #0 * A','[�^�(,`',�/ 4 Cu STc - ed-, �,� I id- ij Site Plan including location
<br /> AGENT ADD
<br /> CONTRACTMADDRESS / of well/septic
<br /> ' 'I/,‘,v Loo_Ell Rd 5 Arnt
<br /> (City,State,Zip) (City,State,Zip) ❑Setbacks
<br /> S,
<br /> 4 lL c Id , ‘v.;: 573 5-C3 S,Qyn 6,
<br /> PHONE PHONE
<br /> Site Plan approval from
<br /> (r e., 93- V'g-to S,g-,-y, applicable township.
<br /> E-MAILADDRESS E-MAIL ADDRESS
<br /> ci 11 0 ' ,+ , ' m 5 d-en t' [ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danemLus/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: [Elevation of property
<br /> ❑PARCELR ! frontage drawn to scale.
<br /> NJMBER Dy©/0507_/33 -NO- 3 S�-" 1 /1 S-
<br /> TOW/HIP: SECTION:
<br /> o f b U ,/4: ,/4: 0 Driveway permits
<br /> ADDRESS: (state, county,town)
<br /> a(0.3 P ,`f,woo:, tOk, s,4 )1S. d.; ce'z .5 3 SW
<br /> [Sanitary permits
<br /> CSM: LOT SUBDIVISIo BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> C 0 0 ticir is q$1 ,'r ,_ 0edie_ in ro c-I Sf14-S0rt 13aidl, ❑ Zoning District
<br /> . [This project is a new building or structure.
<br /> Li Permitted Use?
<br /> Eg This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT UMBER: ❑ Rural Address
<br /> EWER REPTIC t (new/existing)
<br /> HEIGHT IN FEET: / � d F STORIES: (Not including basement)
<br /> 09 0,�,( f1(2 'L 1 4 .11d-IC
<br /> .11IC Cl Wetland/Floodplain/
<br /> Shoreland (attachment) ,f,
<br /> AREA TO NEAREST SQUARE OOT: �A,00641
<br /> y r/ Cy
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) L•� (J��l
<br /> BASEMENT: 1ST FLOOR. ❑ ErosionControl permit
<br /> ,l, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance,
<br /> filling/access)
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> � ° _ ❑ Review Location Survey
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ i c�>c' and available options.
<br /> (Please round to nearest dollar) �5 33
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes [No jDon't know
<br /> 2. Is there a wetland or floodplain on or near the property? [Yes [No EDon't know
<br /> 3. Have you talked with the township about your project and are they in agreement? kgYes No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes No
<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 ,[C Don't know
<br /> 7. Is this to correct a violation? [fres ao
<br /> APPLICATION MUST BE SIGNED
<br /> REV(01/19)
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