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+. ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> o{w�N1eRNAME CUSTOMER TO PROVIDE <br /> F R 1 i4},- <br /> OWNER ER.n Dv, <br /> (Number,Street rtGy,estate. <br /> S /. ,, '' 0 Zoning Status,CUP: <br /> HOME PHONE 5 . '- V// //4 ,-4 Z. .// /0/ - Deed Restriction,CSM ' <br /> �'_ CELL „/ <br /> PHONE E-MAIL ADD: SS b O Variance(/J ) <br /> D'-`7/41 /4 <br /> AGENT INFORMATION CONTRACTOR INFORMATION ❑Site Plan drawn to scale - ' <br /> CONTRACTOR NAM and includes dimensions <br /> AGENT ADDRESS I d I is bL i►. i ' <br /> CONTRACTOR ADDRESS n ❑Site Plan including location <br /> ID C1-�I•1D,., 5 . Cc ti.,14 /` of well/septic <br /> (City,State,Zip) — �•� <br /> (City.sate.Zip) - <, <br /> PHONE f•` `t LA)— <br /> S-.3S3 1, ” ''.11 0- El Setbacks <br /> PHONE <br /> ��b 7S 7D�V 0 Site Plan approval from x <br /> E- ADD-. S applicable township. <br /> E-MAIL ADDRESS yr <br /> tea L A v I, ' may'/( ❑Floor plans to scale T <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) <br /> PARENT PARCEL NUMBER ACREAGE. 0 Elevation of property rr CUR ENTZONING: <br /> NUMBER �\ 1 /3'• <br /> Te SHIP: �tl_�u�.8 X70 l� % frontage drawn to scale. <br /> SECTION: <br /> ADDRESS: v,: CIDnveway permits <br /> 4 k ` (state,county,town) <br /> CSM: LOT O (J <br /> SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PRaecrDEscRlarpN STAFF REVIEW <br /> .-4*11411 C . id;n t, 361 ',‹ Si' r ❑Zoning District <br /> • ,HThis project is a new building or structdre. <br /> QThis project is an addition/alteration to an existing building or structure. ❑ Permitted Use? <br /> SANITARY SERVICE: PERMITN <br /> r--�, UMBER: ❑ Rural Address <br /> I EWER REPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not inducing basement) <br /> ?.../.-/ I ❑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 IST FLOOR: ❑ ErosionControl permit <br /> j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ( 0 filling/access) <br /> 0.0 <br /> ESTIMATED CONSTRUCTION COST: ❑ Review Location Survey <br /> (Please round to nearest dollar) $ i u, u�, and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? <br /> 2. Is there a wetland or floodplain on or near the property? QYes �° Don't know <br /> BYeso QDon't know = <br /> 3. Have you talked with the township about your project and are they in agreement? Yes ° ;s °�.=• <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? fres �lo ,rte <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ;�t <br /> (P PP ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) <br /> [fres DN. Ego on t know a ,.,..� <br /> 7. Is this to correct a violation? Yes �Jo 4i '':, t,I;,`? <br /> APPLICATION MUST BE SIGNED <br /> rrE,(on,9, Contlnueon ck) -i -i -0.9/0,ZL' b <br />