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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 /> A. L( . �, � P 0 �� ❑Zoning Status;CUP;
<br /> OWNER AADDR S (Number,Street,City, tate,Zip)
<br /> 14 ,iia t� e),,, y13 �a d ,, lir . V riaed Restriction; CSM
<br /> 7� j ,i � /� y�(' r ��)_� Variance(# )
<br /> HOME PHONE CELL PHO E-MAIL ADDRESS
<br /> "e '— •• /'`4; $ , 1 4 kA ' _S 6 A fa / ',C ite Plan drawn to scale
<br /> AGENT INFORMATION CONTRACT4,R INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> AGt�. ( I,5(- ) , /�yl, )(3. [ I�)T,` ' ,_) ( C' ❑ Site Plan includin location
<br /> T"ADDRESS •.k CONTRACTOR ADDRESS of well/septic t. A
<br /> cr.A3 vi --Iod --y\e;, l( s''a/ y(i I , . AC r g h ,5 .
<br /> (qty,State,Zip) J(^ / ',(City,State,Zip) Er/J/ Setbacks
<br /> ( f )l/ ern.1 )�{')i 1 `� 1 ` .) --;l._) F,1 ,"-lfr✓-d I •k' w76e,c) P
<br /> PHONE PHONE / ` g--.7j
<br /> ❑ Site Plan approval from
<br /> 1 i(7 C ' s applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> '' 'i �'Y- • ' �(:V--P-Vic" / { 1 ' /.. /..-, `-- , I []Floor plan$to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) (evation of property
<br /> P -ENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: rUrtP p y
<br /> ip •ARCEL frontage drawn to scale.
<br /> A NUMBER Cr! 1 /D.!&-c 7bSt_ A C4 . 7I
<br /> TOWNSHIP: SECTION:
<br /> 0 G /!A) .(1-•"/4: ( ,f\ '/a:-SAN( 0 Driveway permits
<br /> ADDRESS: (state,count/,town)
<br /> 1 Ai '1�i 6-i- -f-e. h-wI 73 �j�f� - sal
<br /> �I � ��� , h � ��-��� ❑ Sanitary permits�I�
<br /> 'CSM: LOT S�1BDI ISION ' BLOCK/LOT
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF REVIEW
<br /> PROJECT DESCRIPTION:
<br /> A
<br /> C () j( ,L.n v ((Ye( ! �'%_,( Zoning District ��11"N-%
<br /> EiThis project is a new building or structure. Permitted Use? C.V'
<br /> ❑This project is an addition/alteration to an existing building or structure. ciVca
<br /> SANITARY SERVICE: ./N//A PERMIT NUMBER: ural Address
<br /> EWER FIEPTIC (n (existing)
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> I li r etland/ ....lIQ�n/
<br /> AREA TO NEAREST SQUARE FOOT: S elan. Mnent)
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches)
<br /> rosionControl permit
<br /> BASEMENT: 1ST FLOOR: j TOTAL SQUARE FOOTAGE: +, (s es,disturbance,
<br /> I filling cess) NO
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> 0.0
<br /> ❑ Revi tion Survey
<br /> ESTIMATED CONSTRUCTION COST: �- and a�ba tions.
<br /> (Please round to nearest dollar) —o.. —ob. ♦ ♦ —lb
<br /> 44!) ', ' ()[;'
<br /> 1, The property is within 300 feet of a stream or 1000 feet from a pond or lake? fres ®No ['Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? Ekes No ['Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? E Yes No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [fres 10lo
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) /(leave,bl., k if none)
<br /> 6. Is a location survey required? (see reverse) tic,) '\o ODon't know
<br /> 7. Is this to correct a violation? DlYes ri o
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -4. —► —►
<br /> REV(01/19)
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