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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App X <br /> 1 <br /> PROPERTY OWNER INFORMATION CU S OMER TO PROVIDE <br /> OWNER NAME <br /> W•1l. r►e1s <br /> OWNER ADDRESS S (Number.Street,City,State,Zip) 0 Zoning Status; CUP; <br /> �, F���k t Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHO E CELL PHONE E-MAIL ADDRESS <br /> c <br /> N 5) �0i - inns t<dc,ck 16se .1 1-',. 1 <br /> 9 N Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C 1 a p He I.,, c ❑Site Plan including location <br /> AGENT ADDRESS CONTRP)CTOR ADDRESS of well/septic <br /> 1v W Gru c, jt. <br /> (City,State.Zip) (City.State.Zip) 0 Setbacks <br /> PHONE PHONE DiSite Plan_approval from <br /> (Guy') S) 7 - 7oYi applipbte township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 1,,t I N4,--c,"j-}r.,.:i'a-,0216? yoLl,,�,.C0^n Q Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL <br /> OW <br /> /o 01 -aft-Vo 0- SFR- 07 0.110 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SE ION 11 ... <br /> 0 47:5,,,1 ; '/a: C:----- 1/4: . 3 Ni ❑ Driveway permits <br /> ADDRESS: ++ (state, county,town) <br /> Cs. LOT SU ° <br /> BDI CtN BLOCK/LOT <br /> 0 Sanitary permits ,j T. . <br /> �. . J (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 0\[! <br /> A,, , `Vli <br /> ..;� ; A,, G r''^t• /L,.r A-d.t.`I•-%.)„ ' 1 �`.�- Zoning District <br /> . ❑This project is a new building or structure. U Permitted Use? <br /> [This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: / C` ❑ Rural Address <br /> EWER /rqEPTIC t'i �ce \I\,j J (newlexisting) <br /> HEIGHT IN FEET: 1 /L-(// I' NUMBER OF STORES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR ❑ ErosionControl permit <br /> Lf 17, <br /> (Nil + TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> (C)&')--0..p ..- <br /> No <br /> '❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -4. ♦ ♦ -.. ♦ . $ ..5-0, 0:,fj 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? Dies ZNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [fres No [ 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? [fres ao <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 EjNo ❑Don't know <br /> 7. Is this to correct a violation? ElYes ONo <br /> il AP APPLICATION MUST BE SIGNED <br /> 19); (Continue on Back) -+ -+ <br /> REV(01 <br /> ' D q (.1 <br />