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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> M o J Y & !i r4 t�/ ----------------- 0 Zoning Status; CUP: <br /> OWNER ADDRESS (Number,Street,City,State,Zip) peed Restriction; CSM <br /> Mil nein h�rttgn Dr Vecony w'r. 531'13 ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> yl4,)ig-710 i 5 ie 11002e ltly/ . CO AI <br /> Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME i /L_J/ CONTRACTOR NAME <br /> I g4Jj 144c diif H Jod)S /3/b15 ❑'Site Plan including location <br /> AGENT ADD SS CONTRACTOR ADDRESS of well/septic <br /> Po Bo( y8'6 r0 Box L 4 <br /> (City,State,Zip) (City.State,Zip) l i Setbacks <br /> t' J Q.)•k 11 c'/ WI DI`t y 9 (1c.i t-•_1I V Wf c 3'H 9 <br /> PHONE PHONE II]Site Plan approval from <br /> G,0%- y Iv 3-)0 99 v oY- r1l3 -.34 9CF applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / <br /> i hgcAtll W .+�'II'Oc1J , c..ern rhardell 04 COIy -c.vn�1 ❑ Floor pla�s,to'ale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENTZQNING: 1 ACREAGE: ❑ElevatlORA#property <br /> El PARCEL <br /> 04 x/o E lef l i i110-o .. ) k '`rX .L,3'30 frontage drawn to scale. <br /> TOWNSHIP:*� L SECTI . ! .--- <br /> /Q+✓+� OT � r�nc) ; . 1/4: ,jam- ' 4. I!vl-, fl Driveway permits <br /> ADDRESS: (state, county,,ttoown) <br /> 1179 MaAhq the)t kr. 1/�/anti ❑Sanitary permits <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT <br /> • 4 Cal.9 •2- (public, private) <br /> PROPOSED PROJECT INFORMATION .STAFF REVIEW <br /> PROJECTPESCRI jTION: <br /> i x4 Liv -iyi-Duna/ Pct 1 /i1-h Auto Covey L1 zoning District <br /> . ❑This project is a new building or structure. It1 1rc,.'id t <br /> '1:1}'Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structur . <br /> SANITARY SERVICE: PERMIT NUMBER: . ► I _ ❑ Rural Address <br /> EWER EPTICf.✓ (new/existing) <br /> ,./--- <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: 1. <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> 1-1 <br /> BASEMENT: 1ST FLOOR: ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: * <br /> filling/access) <br /> ESTIMATED CONSTRUCTION COST: - Li Review Location Survey <br /> (Please round to nearest dollar) ♦ --ii. -4. -4. -4. $ 7 0 q j 0 . 6 G and available options. <br /> J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies KNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes f No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes No <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) Dies RN() ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> ^ •..--- (Continue on Back) -t. -- <br /> REV(01119) 1 a <br />