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L ( --)e.- (X-) (01-1 3 A.1, 7 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS NAME µ <br /> '5C0 I QKe -7& Pte Z cc-11a i ❑Zoning Status; CUP; <br /> OWNENERRADDDRESS (Number,Street,City,State ip) Y / 111 4 ? Deed Restnc n; CSM <br /> OMEPHO E �Oi{,KCEL PHONE `b�i • E �I�DM c C:1-1 1Wt ;S S 7 Variance( ) <br /> 6o%-2s•116 -. zecm.ClS 1 WI r • CO ❑ Site Plan dr n to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and inc s dimensions <br /> AGENT NAME �T . ! V s <br /> 0tKr Ih <br /> i s ❑ Site Plan ncluding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS, of wellkeptic <br /> 5014-111 z93 o A. 5th. 16A4. 14 0 Set ks <br /> (City,State,Zip) (Citty',State,Zip p 1i' �� 1 <br /> 4 7 <br /> PHONE PHONE J w' 6 ❑ Site Pla p royal from <br /> /_o' - 466 — 464o applica t rSship. <br /> E-MAIL ADDRESS E-MAILADDRESS ❑ Floor plpas-to scalelett <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER:/ f '/CURRENTZONING: ACREAGE: ❑ Elevation of (l �� ^ <br /> 0 PARCEL <br /> NUMBER 0q07 ^1�{z'�2 4s -0 a .Z frontage dra to S e. <br /> TOWNS IP: I SECTI N: <br /> 111 O)Cbt4r al 1/4: N (A) 1/4: , ❑ Drivewa rmits <br /> ADDR SS: J I 1 tct (stat rl ,town) <br /> CSM: 5 COu4 oR4, / \S T BG/-,1 WI 53DIVISIO L7 P3T ❑ Sanit r wrmits <br /> 1(22' I <br /> (pUbN'nate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> L + 1 <br /> PIaCG a 5L Ornt. D00.1(at N 2 <br /> (II XL) ❑ Zonin istrict <br /> his project is a new building or structure. ❑ PermitJ Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: none ,«d`d PERMIT NUMBER: ❑ RuralAdss <br /> EWER emit <br /> (new/exW g) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> cb I ed--. ; he'll. _Tr • ' ❑ Wetl 1n 9 dplain/ <br /> y f� • Shor 'h�ll� (oattachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ Eros 1 rol permit <br /> BASEMENT: 1ST OOR: <br /> ' 0)( I" t Ij TOTAL SQUARE FOOTAGE: j (SIO s,disturbance, <br /> �'� filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> U Reviewg.4. on Survey <br /> ESTIMATED CONSTRUCTION COST: 2/ and av1,11-:- options. <br /> __ ♦ ♦ ♦ __ Gt <br /> (Please round to nearest dollar) I#1 sQ 0 •! � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres INo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies '�No ❑Don't know ��4 <br /> 3. Have you talked with the township about your project and are they in agreement? DiesNoM eta (411' P <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [fres �No . VC <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 �.4l o ['Don't know <br /> 7. Is this to correct a violation? Dies ;: No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -+ -+ <br /> REV(01119) <br />