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ZONING PERMIT APPLICATION ww.countyofdane.com SUPPLEMENT to Web-App # <br /> w <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME _ f <br /> M e^ JUS 4t /: tal ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street City State,Zip) ��� Deed Restriction; CSM <br /> S ( /��_//��l C fi i ' 7ct ,Sorl w.f. 5-37/,6 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> d 6 56 ` / ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME Ir. - CONTRACTOR NAME^ <br /> Q-610 ,114 Sv/liuiil mo`e - rn?s litialiall ❑ Site Plan including location <br /> AGENT ADDRESS .)iii <br /> imtof well/septic <br /> — 3av STQ *osy S <br /> (City,State,Zip) (Ci state,Zip) - ❑Setbacks <br /> Sun /Chu P <br /> PHONE PH NE • f�i ElSite Plan approval from <br /> � � 7-7-1/ �G�pb applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS L <br /> M0 trcoNSiff' ?aci a s k,coyh ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.wi.us() ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 036-(Fill-053-7W0-o RR-4 7,93 frontage drawn to scale. <br /> TOWNSHIP: M SECTION: <br /> /// t/)a /: %: Driveway permits <br /> ADDRESS:QG4 Rd (state,county,town) <br /> 0.444 <br /> 1229 BERLIN RD <br /> CSM: LOT SUBDIVISION BLOCK/LOT Ill Sanitary permits <br /> , <br /> (public, private) 3 BR <br /> • STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Slag to crwilily ❑ Zoning District <br /> • N:This 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 EPTIC 13-2020-00313 (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> RO 4 U 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: /I 1ST FLOOR;- nn .cp ❑ ErosionControl permit . <br /> a.'7 r �G 4 TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: bot...+.c 3RD FLOOR: /i�/` �'�eg - <br /> filling/access) <br /> ioaa / v csmf, U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �1 and available options. <br /> (Please round to nearest dollar) $ SCO/ 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [fres ao ElDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Lives Erlo Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes OW <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes caio <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) [fres DVo ['Don't know <br /> 7. Is this to correct a violation? [Yes Wlo <br /> APPLICATION MUST BE SIGNED <br /> REV(01/19) (Continue on Back) —mi. -+ —t. <br />