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ZONING PERMIT APPLICATION www.countyofdane.com Fra=3=7 <br /> I 1 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ` <br /> OWNER NAME 111' tLl 4 �t ��'6�15 1-re <br /> 1�De tLILn a�zs�n t LLL�.. G1 �t/ �]'[) ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> CC /feat •�`/'j��j ` Deed Restriction; CSM <br /> HOMEPHONE "CELL PHONE E-MAIL 53568 <br /> � � Variance(# ) <br /> 4, -r; -1 d , a ' 4:7.3 .1 '4 - d at, el., - . -,k7 Site Plan drawn to scale <br /> AGENT INFORMATION !CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .66.0/7/X z I27- % LSGL�')t;+!.t r� $ ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRES of well/septic 'NCI' <br /> I <br /> d co 5D N WiYir rno(4,1c(. 44 PD )//6. ,eD' t k <br /> (City.State,Zip) (City,State,Zip) 0Setbacit '- -0 <br /> t4)1147 , t�- 'S355 aka 6CI h, LAO' 55575 <br /> PHONE PHONE ❑Site Plan approval from <br /> (Q(A 57(0- 77?'-I liOb - 7&7- 27d7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 6Y-(0, 0 Z /- •t. lam) -. ..a,C / .� / i ❑ 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 ��Q !�/ /,y, ,,LLJ� frontage drawn to scale. <br /> NUMBER Q,7t`.D'/?� (y it-o /1l <br /> TOWNSHIP: SECTIO : <br /> a Q f 015'4A-5-e._) <br /> ` v Y4: ,/4. ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> p2 , / ( C' ! 1 ) 7 4-1-:;rir-. , ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: . s _ <br /> 171./A ti [/ -', .4 katile Sa JdI-r6 LiZoning District <br /> This project is a new building or structure. ❑ Permitted Use? Ckc <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> EWER REPTIC 1,CAI /-7/,t.i I (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> G7c_lifi/ma PeCCX.. i <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 a'— <br /> 400 4, TOTAL SQUARE FOOTAGE: ,, (slopes, disturbance, 31 <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 0.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ 400,4400 and available options. -/ <br /> (Please round to nearest dollar) "♦ "� ♦ ♦ ♦ -40 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ['NoDon't know <br /> 2. Is there a wetland or floodplain on or near the property? oyes ❑('lo DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [les No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank if none) <br /> R la a Incation at.Irvay rcjuired2 (o 90 ravorse) ®Mos.: ❑No ! tiDon't know <br /> 7. Is this to correct a violation? ❑Yes ao <br /> -A -S C.) , APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> REV(01119) <br />