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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 /> :-S-'6•4\IN y 4k-- C .)d_ ❑Zoning Status;CUP; <br /> O NERADDRESS Number, rest,City,Stat Zip) Deed Restriction; CSM <br /> } eC 0KI�� (,C),c 539.E Variance(# ) <br /> HOMEPI-jQN• I CELL HONE Q E-MAIL ADDRESS <br /> OQ PCP vs-yid-goo ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG T AME C NTRACT NAM A. <br /> Et <br /> p�{(,� , ((/i( (2k ec 0 Site Plan including location <br /> AG NT11/411RiSS �'''�1'' CONACTORADDRESS J of well/septic <br /> e(iv t 2 ,64,1„c <br /> (CiN,State,Zip) (City,State,Zip) ❑Setbacks <br /> — Cetki2 (, )r 5301q <br /> PH NE PHONE ❑Site Plan approval from <br /> g- 22.e- 3 J 10 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> �.w , !,i ih�Clr1 1, (pv -I ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:I/accessdane.co.dane.wi.us/) 111 Elevation of property <br /> PARENT PARCEL NUMBER: / CURRENT ZONING: / ACREAGE: �Q ' <br /> ❑PARCELNUMBER 011/4)500'.36l"r ,-s F e. l 1 . l/C9 IQ <br /> frontage drawn to scale. <br /> TOWNSHIP: 4' SECTION: <br /> IP ❑Driveway permits <br /> l�� k t`e, r 14: 14: (state,county,town) <br /> ADDRESS: <br /> ( <br /> ! , (► � � ' El Sanitary permits <br /> CSM: L.,T SUBDIVISION BLOCK/LOT (public,private) <br /> /vr,O A <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 6 rc(i <br /> ,n C „Q (+-, car\ ❑ Zoning District <br /> . ElThis project is a new building or structure. ❑ Permitted Use? <br /> Et his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> :r:'r ER V EPTIC (new/existing) <br /> HEIGHT IN FE t NUMBER OF STORIES: (Not including basement) <br /> 16 1 ❑ 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) r--, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> +, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> �� Q filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ($86 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. ♦ Ur 1 O�� 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 alo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? s o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes to 43 p-+- Ye-4- <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? aes Jlo <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 NVo ❑Don't know <br /> 7. Is this to correct a violation? Dyes <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> REV(01/19) <br />