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ZONING PERMIT APPLICATION www.countyofdane.com suP=:PEM0—i, .o•Wea=App .; : <br /> PR:O.PER7Y OWNE.11:1 N F:O.RMATIO'N • • - . • CUSTOMER TO PROVIDE <br /> OWNER NAME P l Q <br /> Daly 014�t / oldo, S `(A ['Zoning Status;CUP; <br /> OWNER ADDRESS (Number, reef City,State,Zip) Deed Restriction;CSM <br /> S7 5 .ltaG� Q/{��G7 G�/ 353/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6n�5 4"6 5'111 6o 7 Y11b7 5 k r- 00 6? -mkt./, ee'', ❑Site Plan drawn to scale <br /> •AGENT INFORMATION - -- . .- - CONTRACTOR IN'FORMATI;ON, -• and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5 iq )\kIS1-‘, Doro . 645 f 4Jc4t-- ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> P6) QVC Lia ZC <br /> (city,S! le,zip) //f (C� state,zip ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> 60g Z i ( 09 16 applicable township. <br /> E-MAIL ADDRESS E-M e(pn ESQ+ <br /> �jJ ed 6,1 ������ ,___,F1 Floor pians to scale <br /> PROPERTY/LO;CATION `INFORMATIO'N (ti.ttp //ac.cessdane co:d'ane ii: us/) • ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: <br /> ��/� �c' frontage drawn to scale. <br /> NUMBER ,� �L'''('% I, ,- <br /> TOW IP: C SECTION: <br /> e4S 'I 1 �SPrf(1_55 ) 1/4: 1/4; El Driveway permits <br /> ADDRESS: 1 (state,county,town) <br /> I5?7 _CG C`61;6 Q't ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED .P'R.O.JECT° INF OR:MAT-Li3-N.- -_ . '_ .. : - STAFF REVIEW <br /> PROJECT DESCRIPTION: I > / <br /> -' r S)900 foi k a�S e 4; b0;161nee-) !faun-( ❑ Zoning District <br /> • <br /> This project is a new building or structure. ❑ Permitted Use? <br /> ii ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: � 'A ❑ Rural Address <br /> EWER 'EPTIC '` (.4 I b t)C�(� ( (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2151 <br /> f ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> ] �i 5 4' <br /> . 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> /167- 143e-7-- filling/access) <br /> SPi13R: sem: <br /> Nesse. 7W R›•-c11 50 5-01 V -GM <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: i _� _� _� _� ; D��1od 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 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eves , CNo 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 FINo <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) [les :No -Don't know <br /> 7. Is this to correct a violation? [fres to <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i► -► -. <br /> REV(0tf19) <br />