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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 /> -G r/bey -b 1 X I L J�' iS�A) ❑Zoning Status; CUP; <br /> OWNER ADDRESS ( um Street,City, te,Zip) 5341 Deed Restriction; CSM <br /> .30 3 c ' -/ Inc 4-J. m 1 ' Z.r't,c-.4/41 Lk)L. Variance(# ) <br /> HOME PHONE CELL PHON E-MAIL ADDRESS / <br /> -0Y-SOf - , 2' ' C>r ti-SLS' • ',S 0) H,k o • C in ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Biwc r11 :,j, le I ev, '^(J...0 ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOr.,DDRESS J of well/septic <br /> N 89 15 WkliG Sf- <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> $1∎11f,r I III. tar 535.4 <br /> PHONE PHONE I ' ❑Site Plan approval from <br /> (000.. I�1 . 00to I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑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 /> frontage drawn to scale. <br /> NUMBER ;o500)–3(O('84(.30–a �.t4'�Z �J <br /> TOWNSHIP: SECTION: <br /> 1 biA)S� pi— O f ec c-)9 %: '/'/.: ❑Driveway permits <br /> (state,county,town) <br /> .1131 Vhtt ea, Ore. in . �'� 63 /5 <br /> ['Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5 lbr4 Ii i. ❑ Zoning District <br /> gThis project is a new buil ng or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [)EPTIC — (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> r if Y( t ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> aprox 1,15Z. ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ '' -♦ '♦ $ i 5 I COD . t? and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes Es. ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes alo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes NiNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies 1410 <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) Elves Ell10 ['Don't know <br /> 7. Is this to correct a violation? plies alo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) - <br /> 545-112(4/08) <br />