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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPP}Er,RTY OW <br /> NER INFORMATION CUSTOMER TO PROVIDE <br /> o I r t wfwan ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Num e�4,,City,State,Zip) <br /> Deed Restriction; CSM <br /> HOI ON. CELL PHeNE E-MAIL ADDRESS Variance(#C UP 2462 ) <br /> v ' 1 "✓ ► ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> way, n -�Q'� C CTO NAAME �Q'n�I�`C�� cel l j 9 •` �(,1`�rs ❑Site Plan including location <br /> 74,5\Dzssio6 w(041NT.E. ICCEr <br /> of well/septic <br /> r\ fl V-- b 1� 1 �/ 1 <br /> viltz`o na a(v motaznauLt ❑ Setbacks <br /> El Site Plan <br /> approval from <br /> gOlf(f)SO PIN <br /> c,,crip_uu <br /> applicable township. <br /> -MAILAD 'ESS ('� ( � -MAIL ADD ESS <br /> \ ttS ,, l LV--- O1e_. S ' 2 it ' ► S . (Dr` ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL 0712-123-9960-0 LC CA f) frontage drawn to scale. <br /> NUMBER <br /> TOWNSIP: ,/�r'fi CTION: <br /> 1 (/J�`[/�Y OctJ/Ltl /vIA: 1/4: 0 Driveway permits <br /> (state, county, town) <br /> ADDRESS: (otflh1f <br /> 131 l /' <br /> SUBDIVISION BLOCK/LOT ❑Sanitary permits 4 BEDROOMS <br /> CSM: T <br /> 15 Z3 (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJErD "ION: „p en int\aL pcvsli1 p c_hcnNil Zoning District <br /> • [This project is a new building or structure. VI Permitted Use? CUP 2467 <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address Ex <br /> EWER 1-41;71C , ..—'2C`�1 DC)\ �� (new/existing) <br /> HEIGHT IN FEET: i NUMBER OF ST RIES: (Not including basement) NO <br /> �b N 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) ni <br /> Sdi BASEMENT: 1STFL0 R: <br /> ErosionControl permit <br /> I �O c5 2185 .. 3757 1 TOTAL SQUARE FOOTAGE: 1 (slopes, disturbance, <br /> zw o c3�ne+' 3RD FLOOR: filling/access) EC2021-J200 <br /> kp 71F 5942 <br /> v�'Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -' -4 <br /> -4 '' ♦ $ 665000 and available options. NO <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 ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Ye No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ILITes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blankif e) <br /> 6. Is a location survey required? (see reverse) ❑YesDon't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> $ 644.20 APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -► -4 <br /> REV(01/19) <br />