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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NAME _ <br /> R`e-k v-` L'4 3-' (‘ Sin tt1 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) x Deed Restriction; CSM <br /> l q 0 ''? t3c,„../. E'Sz\-- Aouk_91'=-..car, L3 ( s C3 c)--'‘.' ` Variance(# ) <br /> HOME PHO4'6-oa CELL PHONRC."0- i E-MAIL ADbRESS <br /> 3 - _ ^7 II '3 I ,4c q —43`sb Ai CI c1.) ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ft.,►,„, , .(r <br /> _e�.�ke.)-2 ‘v\. lit_v— ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (C,�iittt?)State,Zip) ❑Setbacks <br /> PHONE PHONE 0 Site Plan approval from <br /> (Cock,\ cv ;ty 3 3 5 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARfrontage drawn to scale. <br /> NUMBER <br /> ( j V/ (� p 2 I t�`�S <br /> TOWNSHIP: 04"I C i� ,L Gls`L'�() SECTION: '"ii;w."&k.• n �z <br /> 1 Pp...,-,_, <br /> El Driveway permits <br /> 0,-. - G /a: 6n7 /a: o <br /> ADDRESS: (state, county, town) <br /> 191 o +? .Ro. i,. v- _0'� S'Z t ..;Lct t,- -k, (.i l 5 3 Sl'1 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> /S '7y ' <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> S—te>N,_e 1..-ck -,..______„5*v._z A ❑ Zoning District <br /> . 2This project is a new building or structure. ❑ Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER E)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /0 .-c"-i- , f•t l S ( ❑ 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) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> Li o Y (o 0filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 0.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -41. ♦ ♦ ♦ ♦ —10. and available options. <br /> (Please round to nearest dollar) G, del '' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? aes ❑No EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? 12Yes ENo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Wes ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes QNo <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) Ores ENo ❑Don't know <br /> 7. Is this to correct a violation? fres ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ ♦ -+ <br /> REV(01/19) <br />