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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 /> Ll( dR "d G c1�cy,State,Zi.) ❑ Zoning Status; CUP; <br /> OWN RAD SS (Number, Deed Restriction; CSM <br /> I <br /> • _ ' A , 4- " 5� Jr Variance(# ) <br /> HOME PH+ ,CEL'PHONE �MAILADDRESS <br /> 04 -� '66`/ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> 'AGE T NAME CONTRACTOR NAME <br /> °`14-4 y W. Shint-Of,/S' 11110 Y1-5.0(4...1 _,(.5' ❑ Site Plan including location <br /> GENT ADDRESS CONTRACTO yDDRESS of well/septic <br /> (km,t r. 5/ A LA-,---...— <br /> (City,State,Zip) (Ci te,Zip) ❑ Setbacks <br /> Are_ °reS-7--(0 3-3.5-_ ' <br /> PHONE - NE �❑Site Plan approval from <br /> 3 - : f' applicable township. <br /> E-MAIL AIL AD ESS <br /> ❑ Floor plans to scale <br /> ...: car Cc J' G _, eNw..- <br /> L PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NU BER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL O L "o Q/6- frontage drawn to scale. <br /> NUMBER L.J UU / �(�_ •iq �� � -' �K1 <br /> TOWNSHIP: SECTION: <br /> �� '.n, sa f 11-O[_ to 51/ 1/a1/a. ❑ Driveway permits <br /> ADDRE-SSA (state,county,town) <br /> J 70 '1•w.5 c c_ OJ. De:F.; Y - 7 l • 5:75:7 —'� Sanitary permits <br /> - CSM: L T SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJ T DESCRIPTION: i I a' <br /> e w to o �S e_. 0 Zoning i IS , + <br /> This project is a new building or structure. 0 b <br /> • <br /> P ag T- <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> (SEWER (SEPTIC /3 —pC 6 t, —6 n0 9. a-- (rte' <br /> ..o •} f <br /> HEIGHT IN FEET: N DARER OF STORIES: (Not including basement) <br /> �— 6 �� /U 5=-AD ps L Weil d/Fl dp(ain! <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: !r <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) �y'Off' <br /> Li E1 11U'rt 't1 Ot a t''. <br /> BASEMENT: _ 1 LOO <br /> ((QJJQ\5∎7 T 4, TOTAL SQUARE FOOTAGE: 4, � s 1(r S,{ UI }e�tCem <br /> 9ias.)0 , <br /> 21D FLOOR: 3RD FLOOR: <br /> L1 Revievittpcation Survey <br /> ESTIMATED CONSTRUCTION COST: $L ^a and B <br /> (Please round to nearest dollar) ♦ ♦ ♦ "♦ ♦ ♦ �P �o .- `�C/ ;w,,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IS No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes p No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes A No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑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) ❑Yes No p Don't know <br /> 7. Is this to correct a violation? ❑Yes KNo <br /> 6 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) 5-6- (Continue on Back) <br />