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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME y <br /> '�! _..�/4 k. , 0 Zoning Status; CUP; <br /> OWNER <br /> ��ADDRESS <br /> /(Number,Street,City, tate,ZIP>.) Deed Restriction; CSM <br /> c2/7� L1'7IC j i s' `m hr I 1/71- S35- 2 5 Variance(# ) <br /> HOME PHONE CELL PH NE E-MAI DRESS <br /> 2.20 S'5/ /771,•iee41e1rkc.;ct,..knk e Cerelon 0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> C' :'7DDREl Site Plan including location <br /> AGENT DRESS CONTRAC OR AESS of well/septic <br /> (City,Stateip) r' (City,State,Zip) ['Setbacks <br /> PHONE ' PHONE ['Site Plan approval from <br /> ,.. <br /> � ` _._ applicable township. <br /> MAIL ADDRESS E-MAIL ADDRESS <br /> [' Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) nElevationofproperty <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: <br /> 0 PARCELfrontage drawn to scale. <br /> NUMBER 061.;22A2 a <br /> 5z -.- "7Q <br /> TOWNSHIP: SECTION: <br /> li LI �`�a G,�c ' � IA: /1 w �;_ / 41/ E] Driveway permits <br /> AD KESS: (state, county,town) <br /> ADCESS: <br /> A 11, e0 ,Q &A ,i,„,:s tv:1 5 3 5- 2 3 <br /> CSM: LOT SUBDfCISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECTCRIPTIO : <br /> 9 e,/4r, '',/,7,t/1 ,S.:4-,, - 0a > ❑ Zoning District <br /> . UThis project is a new building or structure. ❑ Permitted Use? <br /> i:El,`This project is an addition/alteration to an existing building or structure. Atr— <br /> SANITARY <br /> SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> GP. _._ (new/existing) <br /> HEIGHT IN FEET: —NUMBER OF STORIES: (Not including basement) <br /> 4 / _ _ ❑ 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 /> ❑ ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> /� y j TOTAL SQUARE FOOTAGE: a (slopes,disturbance, <br /> 5e7e6.9 ------ filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 0.0 <br /> U Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ I <br /> WO and available options. <br /> (Please round to nearest dollar) ♦ ♦ S <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes Ir o Don't know <br /> 2. Is there a wetland or floodplain on or near the property? nYes ** o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ['Yes ENO <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes MiNo <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 jgNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ii No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -♦ —► <br /> REV(01/19) <br />