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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 /> e.rl . 1:›4 w''. 14 q'".6 O teL n Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, Deed Restriction; CSM <br /> NE <br /> 73 Pee 1�,c x4 I`L�C ...AX., h it ' Variance(# ) <br /> HOME PHONE 1 CELL PHONE Er 4'4_ E-MAILaRESS <br /> Ge'—S/ -3. - ' [Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / / CONTRACTOR NAME <br /> 17q4.- /Y�i a B IA- [Site Plan including location <br /> AGENT ADDRESS Rid) , ONTRACTOR ADDRESS of well/septic <br /> .73 PI kie r no IA <br /> (City,State,Zip) I-4, <br /> SAI City,State,Zip) O Setbacks <br /> _ T�u a0 W=1733: <br /> PHONE a 1NE O Site Plan approval from <br /> 6 A r_ 7/-2 _6-6 Q 2 applicable township. <br /> E-MAIL•DDRESS •ILADDRESS <br /> ,� it Wg 49 Jai_ 0 Floor plans to scale <br /> PROPERTY/LOCATIO'4 INFORMATION (http://accessdane.co.dane-wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CU RENT ZONING: ACREAGE: <br /> Ei PARCEL j 5 / —>1412-”z 47'/ .5// Q�3 ' frontage drawn to scale. <br /> NUMBER f 1 /� J '� <br /> TOWNSHIP: SECTION: <br /> /AIA.LI r 0 /y ,/4: 7-57d2,/4: ,el,/E 0 Driveway permits <br /> ADDRESS: (state, county,town) <br /> 973 "elm to O Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCKJLOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 3 Se a,3c•. s r L\,.. ❑ Zoning District <br /> . ❑This project is a new building or structure. <br /> ❑ Permitted Use? <br /> 54.This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER VMEPTIC (new/existing) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> l / 1 ❑ 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 /> .7 p S s 4, TOTAL SQUARE FOOTAGE: l (slopes,disturbance, <br /> Z filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 0.0 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -1. ♦ -1. (J �O© IDD and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? OYes No Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Oyes EiNo ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? OYes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? OYes 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) Oyes Do ['Don't know <br /> 7. Is this to correct a violation? [Yes `f o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —i <br /> REV(01/19) <br />