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r <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ''/V -- .L/C 5, '67c YCL ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 5896 N1 BE,e/N/I,eJ (JT Variance(# ) <br /> HOME PHON CELL PHONE E-MAIL ADDRESS r ('' <br /> 77 -S - -/Y 7z 22 y-9vy-34 re//'�/ ye.J�/x� ,<'o , <br /> or �-,e ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS 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 ZONING: ACREAGE: frontage lev drawn to scale. <br /> ❑ NUMBER <br /> PARCEL o5'/2 —2Sy-3 7E-1_6-' <br /> TOWNSHIP: SECTION: 1/4 1 1 CI Driveway permits <br /> j�GB/O N : /a/a: (state,county,town) <br /> ADDRESS: <br /> 3 95 La 5r/o,,e6- DR- D«,e��,/t) ��/9ey s�33 y ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION .STAFF,bREVIIEW <br /> PROJECT DESCRIPTION: <br /> f/O USE /S/A!h—.. ❑ Zoning District <br /> . ❑This project is a new building or structure. ❑ itted <br /> permUse? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: U Rural Address ,, <br /> ❑SEWER ❑SEPTIC <br /> (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 4):1-e(41/ <br /> Shorelan (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including untinished area,attached garages and above grade decks or porches) ❑ Er`oslonCo ttrol permit <br /> BASEMENT: 1ST FLOOR: <br /> j TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> fiillingfaccess) <br /> 2ND FLOOR: 3RD FLOOR: A <br /> Cl.Review Lo ation Surrey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -r ♦ -► $ 2 c) coo, co afl aYa/ ?le Option. <br /> (Please round to nearest dollar) ,-4.`,',P7 - _~ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? laYes ❑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 tgreement? aYes ❑No <br /> 4. Has there been a zoning permit issued for this p l years? ❑Yes c No <br /> P <br /> 5. Is this project associated with a rezone/CUP/va0 petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) 1 .10 ❑Yes ❑No aBon't know <br /> 7. Is this to correct a violation? 1/ ayes ❑No <br /> GhG � 16 <br /> Q 411 APPLICATION MUST BE SIGNED- <br /> 545-112(4/08) DOt°1 r1 (Continue on Back) ■ ■ -+ <br />