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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 /> 3-1-eve 4e� RIC o4.,,,,min 5 ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3I r"1 S Pa(56441 Lane-) S u h fbY1 / tot 5356 Variance(# ) <br /> HOME PHONE I CELL PHONE E-MAIL ADDRESS <br /> 1—. 1.0.—£3735 Can-in-We.. aeon) a + Ale- ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Oopper Raqt tayprred-rave ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDREIA of well/septic <br /> 18I 5, 13r'l:.l kt D Q— <br /> (City,State,Zip) (City,State,Zip) J ❑Setbacks <br /> Si-D9 h fD0/ lA-x .53Sb9 <br /> PHONE PHONE ❑Site Plan approval from <br /> 3314- 14so applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 1114-a_rra41 -ac O 1401-.cowl ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: <br /> / CURRENT ZONING: ACREAGE: f <br /> ❑PARCEL NUMBER a'7. Z J 7g.3.�it ✓6� 0/. l frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 1��n n 1/4: 1/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> 31q 8 pot-a1 St,-W4 Lt- -) S iNkbn, tool .53Q:1 ❑Sanitary permits <br /> CSM: LOT S (VISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> baMU GX.M7YIyQ 652 4- e" 5 r.tct Mew Fe. U Zoning District <br /> IgThis project is a new building or structure. <br /> ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> NEWER [EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> LI 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 /> 100d`/) ^FL14J laq / O'1- j TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: / 1 D filling/access) <br /> U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -iii. -I. -0. ♦ uv and available options. <br /> (Please round to nearest dollar) $ �a --� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ages ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No a Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®.Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [fres 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) [X]Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 2No <br /> APPLICATION MUST BE SIGNED <br /> REV(01/19) (Continue on Back) -+ -* <br />