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• • C6 3 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> � <br /> AN jc_A-kv,L , <br /> OWNER ADDRESS (Number,Street City,State,Zip) ❑ Zoning Status;CUP; <br /> 4 S-5-9 , SAND R Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE <br /> E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION <br /> CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> "C.)RS-re& C c-Taira t..l,.0 - S1v1E' LI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS g <br /> 4WS6 1-11 L— -J of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> d(r�t:CooQ , uJi5 S 595 <br /> PHONE t„„0y3 -635-- sack O+ PHONE ❑ Site Plan approval from <br /> 6:,`6 a I Q - 909E3 11 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> toa' lb,r ors-er-tca5'trv,e.t,o,., ,c.o.Y1 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us,) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL <br /> NUMBER 05.), c-.`OS/D-3 -$410 A-/ (E X K-! R H-1 a .as-') frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -j'o�:,a OP CkLTLANc 3O '/a: 5.E %I A: AW ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 4559 W, Zu11_i0N0 Ro <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> ) )S Co 9 ' (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> °e <br /> PROJECT DESCRIPTION: r ' <br /> 1-\au5C Phu AQ.ACoC ADo,-r/dN - '; l x v- <br /> • ❑This project is a new building or structure. €, <br /> liyz` <br /> This project is an addition/alteration to an existing building or structure. - e - ,,i <br /> SANITARY SERVICE: PERMIT NUMBER' zr - e}_ z °;�3i, <br /> s1 <br /> ❑SEWER SEPTIC a , <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> A'' • TO NEAREST SQUARE FOOT:r��',' <' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) " r> <br /> BASEMENT 1ST FLOOR: ® a ri t : <br /> 3 G <br /> �' l `�� � 4, TOTAL SQUARE FOOTAGE: 4, A ,..4,%;:,''''‘....;,,ate' ' <br /> 2ND FLOOR: 3RD FLOOR: t , t <br /> ESTIMATED CONSTRUCTION COST: y &; . <br /> (Please round to nearest dollar) '■ "■ '■ ■ —► ♦ ii .,..› 0 , . •l • = g: �z � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No $ Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ,Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes Flo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 'Yes ❑No -p C7 b <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 ' 51No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► —t. <br />