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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> a J dg CO CNA;t.ar SCOAtt Fg I-4e— __ 0 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3.7)-6 i safer i c:r.Gq k or. if'-.'c11c We , 3 `i.3 Variance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> C, —3j1;-2 31.22. co d h i CI 4-41 f4 .t a7 c Y+„ 4.1. Co+' 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> R 4 eicV{ )4 qr•cir if, 4- j'L i i 5 . chis Site Plan including location <br /> AGENT ADDRESSCONTRACTOR ADDRESS of well/septic <br /> fa 170,,,,, tb1 ege)e vsq,:, <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> lici' 016, Wt, S.5'111 i100.441i01 evr- 3-3 q Y ci <br /> PHONE PHONE ❑Site Plan approval from <br /> Coq'—03~30 '991 Aart1r t,Cb'- 03-1©41(1 4,149 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> rlige 4; t Il a '1 coli (.. - r" Mit r ei-t_)1 a'..v 1 'Coil y corn ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: EJ <br /> ❑PARCEL �y frontage drawn to scale. <br /> NUMBER !(�� aTC�.-L�3''LiMd"Ci � 811 <br /> TOWNSHIP: SECTION: I--I <br /> M iti ti }<,+oh X1 1/4: NW ./: 'b it/ i l Driveway permits <br /> ADDRESS: (state, county,town) <br /> 3:5-(4 4 5....11W;0/ Oak Dr.. Vtr4 ,,;; i4(1. 6-3513 -to 1, ❑sanitary permits <br /> CSM: LOT i ,SUBDIVISION BLOCK/LOT (public, private) <br /> 7V `1 9 ram bit.clovn Aitegl <br /> PROPOSED PROJECT INFORMATION ' ''''STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> L.01k` I ' £ri yc. t,d ( J raft t-t+ ay,t.-i: ccy2.-9' Li Zoning District <br /> QiThis project is a new building or structure. !i Permittee( Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: ', PERMIT NUMBER: <br /> --- U Rural Address <br /> EWER [)EPTIC (new/existing) <br /> HEIGHT IN FEET: TNUMBER 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 /> - - ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 4TOTAL SQUARE FOOTAGE: 4, (Slopes,disturbance, <br /> --- _ tilling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> goo sy��t <br /> is Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: 1 ♦ ♦ and available options. <br /> (Please round to nearest dollar) 'p 73; 3)-0.00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes No QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes EINo QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Efres kENo <br /> 4. Has there been',a zoning permit issued for this property in the past 5 years? Dies 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) fres 11No QDon't know <br /> 7. Is this to correct a violation? ]Yes , lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —. -♦ —► <br /> REV(01/19) <br />