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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> / <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Pekr- S'c ra IA A n.t P .St Vi-- O Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City State,Zip) Decd Restriction;CSM <br /> !.2 3. old ciw_Ooo L lirt, Vi_ ���Z I Variance(# ) <br /> HOMdog i36'09 1 [y3 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION fdnd includes dimensions <br /> AGN NAME CONTRACTOR NAME, <br /> Y A fvvk r.S e v 1 L. —fell.( 4 Bite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS ;of well/septic <br /> (42. 9 D1ots �L Q' 493D 0101 04,54- <br /> (city,Sta %z (7 (c; te, ) nSetbacks <br /> kins� 176, UT SZI yP 5,V` Elite Plan approval from <br /> PHONE PHONE 6 b g SY b 09 7 f 6o e sr-s-2a orz ;pplicabte township. <br /> E-MAILADDRESS E-MA DDRESS i _ <br /> .J ! . , c_ZZ ,0 , 4 i "`r ©Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: <br /> � CURRENT ZONIING: ACREAGE: 0 Elevation of <br /> f property <br /> ❑PARCEL <br /> C.-,"J1 L 11/^aO RR- I " g Q frontage drawn t,-sca <br /> le. <br /> NUMBER <br /> TOWNSHIP SECTION �c/'✓ i <br /> 2.4-+ 4 xi 1A: 1A: '/vliE❑Drivewaymits <br /> ADDRESS (state,Odunty,town) <br /> CSM: LOT SUBDIVISION OCK/LOT Sanitary permits <br /> 110� ,/ (public private) (/ <br /> / <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �� <br /> e.Q preaki .Q� <br /> A 0 U Zoning District <br /> . This project is a new building or structure. 17(C "(c L Q Permitted Use? <br /> 01-his project is an addition/Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rural Address <br /> EWER [EPTIC U\v1 14- (new/edcisting) <br /> HEIGHT IN FEET: NUMBER 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 /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> .%-e"' &` j TOTAL SQUARE FOOTAGE: , (slopes,disturbance, I <br /> v v <br /> ,k.1,,,.--,,,,, filling/access) <br /> 2ND FLOOR: 3RD FLOOR: ' <br /> (o <br /> 1, r ;�ifl; 0.0 V _ „I , <br /> `• U Review Location Survey ; <br /> ESTIMATED CONSTRUCTION COST: ¢ and available options. <br /> (Please round to nearest dollar) -o. -* $ 70 v v V <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [fres OW ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yeso �on't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑', s Olo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [v]Ye ' ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leaye blank iffione) <br /> 6. Is a location survey required? (see reverse) [ayeso ['Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -► <br /> REV(01/19) <br /> r <br />