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-13`33 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME L/5 <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> By/0 J/1 -0'1a,u-K-- <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> -7?,3 3qc'-1a-xx, X75 3ya kia-o ' (-Q VV opidol a ucsCe-i/alit•cam ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> / .3q '') x-d-, Conc_erU L 1,1(11_0-^- ❑ Site Plan including location <br /> AGENT ADDRESS , ADDRESS of well/septic <br /> 50 5 E. �atC�-/Zs suas O�G 5-0 s Via.+- do-q- <br /> (City,State,Zip) / (City,State,Zip) ❑ Setbacks <br /> `T(-L 'moo IL (0000 '- - /4 LL-0..ao !- LoUC)C)S <br /> PHONE PHONE ❑ Site Plan approval from <br /> 'Lilo Lt03 5/03 8`F 7 9'8 / off} d 3 applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> /,b1-rrrt6 COrtcar?),ct x)/TV csSccaen d'nscldaf-e,Conca.--dJ.C.f ul%WeIISS•( ❑ 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 /> III PARCEL b.7/A o-/P 0- L.- 4_ 1 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTIO : <br /> D- ---- `"`e_i_0� '/4: N C 1/414: N vv ❑ Driveway permits <br /> ADDRESS: _ (state,county,town) <br /> ,-/LD cl.Q c5t R�cAd 7 3 0� i. <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private <br /> aztacl�r,..l._: N t A, Al/A- A//�4- (P private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ct tr- yp-(parr-Q {yam 14-,- -L,y4E4 <br /> ❑ .a,t bed Zoning Cistrct <br /> ❑This proj ct is a new building or structure. ❑ Permitted Use? <br /> aThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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 /> ❑ SrosionContrtl omit <br /> BASEMENT: 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturb, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: of ❑ Review Location Survey <br /> (Please round to nearest dollar) <br /> .♦ -. ♦ ♦ ♦ ♦ 4 S, o 00 . and available Options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes allo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes 1.1No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 2Yes ❑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) a Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes oallo <br /> 545-112(4/08) 1/ APPLICATION MUST BE SIGNED <br /> (Continue on Back) .-4- ♦ --► <br />