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• <br /> ZONING PERMIT APPLICATION ww .countyofdane.com SUPPLEMENT to Web•App# <br /> w <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> a 'e ' i70r ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number, treet,City,S te,Zip) <br /> Deed Restriction; CSM _ <br /> /O G'r<iiL1// �yl Variance(# ) <br /> HOME' PHONE CELL PHONE E-MAIL AFDRESS <br /> 1--/55-604X, ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA'TOR NAME <br /> / /:/tezr 1 re(if li'a f Ce 7L (}e . rL ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Litt') l/t'iz'-t C {" 4'/I/ <br /> (City,State,Zip) (City,State;,Zip) ❑ Setbacks <br /> 1 e k-d7i/Gt w." S-. <br /> PHONE PHONE i ❑ Site Plan approval from <br /> �C<` .- q(�713 applicable township. <br /> E-MAIL ADDRESS E-MAIL A4DR SS <br /> i- � --- e f f I 1 X't s� n Pi ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dano.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ONING: ACREAGE: CI ElevatlOn of property <br /> PARCEL 05409- 61/ 943 NUMBER ∎' n frontage drawn to scale. <br /> TOWNSHIP: SECTIO Imo: <br /> ���I'c'y 2J, Ya: S� /aYa: ❑ Driveway permits <br /> ADDRESS: / (state, county,town) <br /> Lilo -o f`x'61 e 4 h ❑ Sanitary permits <br /> CSM: LOT SUBDIVISInN i 4t BLOCK/LOT <br /> y s t (public, private) <br /> PROPOSED PROJECT INFORMATION �`"� STAFF REVIEW"""' <br /> PROJECT DESCRIPTION: r � <br /> 7L9 4/ ,L3( -�-7 ❑ zoning District <br /> ❑This project is a new building or structure. I ❑"Permitted Use?:' <br /> UlThis project is an addition/alteration to an existinglbuilding or structure. <br /> SANITARY SERVICE: PERMITNtiMBER: ❑;RuralAddress : --- <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER CiF STORIES: (Not including basement) <br /> j Li Wetland/Floodplatn/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> l tt1SIt3Rttrvj(�3kt <br /> BASEMENT 1ST FLOOR: ._ TOTAL SQUARE FOOTAGE: (slopeS� htttuu <br /> 5(0 �� l <br /> ning/a ss <br /> 2ND FLOOR: 3RD FLOOR: :„4 <br /> ESTIMATED CONSTRUCTION COST u Review Luce O Slimy,34 5 1 <br /> 'C°�3 <br /> (Please round to nearest dollar) "p "4 "o "p cn ( avS113ons <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? CI Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? CI CI No <br /> 5. !s 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 /> i0 `0 <br /> t ,© APPLICATION MUST BE SIGNED <br /> 545-112(4/08) 5 �(J� (Continue on Back) -► -* <br />