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,7a - 4? <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AME p <br /> , e•iye-ti A. a/t/6-c/C 0 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 9*2/•C- 04° loo /CdAcd Sa� 6.Y, <•v. • -3 --Y 3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Got-b/3- k9 4.0e-9lr,7-,i.38 _ . A,'L. Le rrl ❑Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME I- A.1414040� <br /> ihe/48.4"es ,J J, 4,14.f ©Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> C wz sYa,..✓K VA)/y' ge <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> SA 1i r?d7Y/QF- 53-47-3 <br /> PHONE PHONE ❑Site Plan approval from <br /> 4t"g- 393 - 996,2 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> /if-C.24.c/ e 5 ivA 1 , C®ni n Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: El <br /> 0 PN <br /> PARCEL 9O7'062-SQsol — o <br /> go �/`J�+ /, ADO o G frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> oX eu r Y 69-7 1�' ��4 <br /> F ' s fl Driveway permits <br /> (state, county,town) <br /> AbbDRESS: �/ <br /> /D A' 6 'a (i7, -O 'C` - -S ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJE T DESCRIPTION: <br /> XI%y.e_ GXi7)"'g /'� .- ASA ,( ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> ©This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> N/A (new/existing) <br /> EWER �EPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain) <br /> i.? f��rA/ ' / 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: (slopes,disturbance, <br /> j TOTAL SQUARE FOOTAGE: , (SIO p <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1/ <br /> 4.O <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -► ♦ ♦ $ �. '6 - oo 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? EYes ENo EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes ENo f Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dies ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes JNo <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) EYes ENo EDon't know <br /> 7. Is this to correct a violation? Dies ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -+ <br /> REV(01/19) <br />