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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 /> fju e, R' ,)e. r Ai Sum?y LL.c Li Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> .70 Oji J-j,,,,y 5'I Un;-t - L/ Variance (# ) <br /> HOME PHOME CELL PHONE E-MAIL ADDRESS <br /> 608 491-1 yl 4; 60S 4/b`/ 0sia5/ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) - ❑ Setbacks <br /> PHONE PHONE U Site Plan approval from <br /> applicable township. <br /> EEADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wius/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> ❑ PARCELfrontage drawn to scale. <br /> NUMBER �jS 1 � �3?�I� tU�W� `0 <br /> TOWNSHIP: SECTION: <br /> 141L i o e--, 9. -7 1/a: O S E 1/1/a: $E ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> I 7° -L Y ki''` + ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> nem ,j\ - premr5L adue_r4iS1 '1i SI-, i-N ❑ Zoning District <br /> . Li This project is a new building or structure. Li Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not Including basement) <br /> 14110 <br /> Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: `'ice Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) i—, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> ,i, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. -0. ♦ ♦ ♦ �I and available options. <br /> (Please round to nearest dollar) $ (.0C.,C,6 .)..� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EA No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IA No Li Don't know <br /> 3. Have you talked with the township about your project and are they <br /> �*in,, l aN ht Li Yes 4ci No <br /> 4. Has there been a zoning permit issued for this property int , a°�'t6year ? ®Yes ❑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) s ...1`. ...VID........ LiYes I No i❑Don't know <br /> 7. Is this to correct a violation? 1 Yes ❑No <br /> DO'r4191APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —0. —► <br /> 545-112(4108) <br />