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ZONING PERMIT APPLICATION www.co ntyofdane.com SUPPLEMENT to Web-App # <br /> ' PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> M&r I'6ra- _Zoning Status;CUP; <br /> OWNER ADDRESS-"(Number,Street,City,State,Zip) 6 �p <br /> x,14 S4✓- ��s-}- j ra►YL e. Deed Restriction; CSM <br /> °� Le) 1 �� �� Variance(# ) <br /> HOME PHONE CELL PHONE E-Iv1AILADDRESS <br /> 1908 8 a6' Q+y f3 leo 8_ 34}ii~09`t l yytr s Beira.. Q LI L.)e%.ed M. n ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of vv ell/septic <br /> (City,State,Zip) (City,State,Zip) - Setbacks <br /> PHONE PHONE � Site Plan approval from <br /> plicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT Z ING: ACREAGE: p p y <br /> ❑ PARCEL CC1 I 1 _� I--)q/c1_ - j / I/Vat-re. frontage drawn to scale. <br /> NUMBER J C� <br /> TOWNSHIP: SECTION: <br /> .I�' Y't SjrD k ' ,-,9 1/a: r■J'L 1/x14: N 1,,.1 ❑ Drivew rmits <br /> ADDR 7 L � C/k 4 /L (Stat , o ty,town) <br /> ❑ Sanita p-rmits <br /> CSM: LOT SUBDIVISION S., LOCK/LOT (public •Nate) <br /> PROPOSED PROJECT INFORMATION STAFF EVIElfft� <br /> PROJECT DESCRIPT}} N: 1 � <br /> Li, I aL A e �- T D P-1-'1 x I LV c 'd Zoning District <br /> . ❑This project is a new building or structure. Permitted Uses: <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NU ura <br /> ne istfn ›- <br /> El SEWER cia SEPTIC , (. <br /> HEIGHT IN FEET: NUMBER OF STORI : (Not including basement) " x <br /> ❑ wetlan odpiatn/ �' <br /> Shore( (at chmen <br /> AREA TO NEAREST S UARE FOOT: e <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOO El ECo3tOn +" of permit <br /> 4 TOTAL SQUARE FOOTAGE: 4, (stop- ,,� turbance , <br /> filling/acee <br /> 2ND FLOOR: 3RD FLOOR: -q 6 � � <br /> ❑ Review Lo etie Survey <br /> ESTIMATED CONSTRUCTION COST: ;,and-avaltae I. options <br /> (Please round to nearest dollar) $ .5 / b b D.UD yw.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ' ❑Yes Xi No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes al No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ❑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 ❑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) —► —► —► <br />