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I- . <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to web•App# <br /> PROPERTY OWNER INFORMATION :, .r _ l= .: d w' 41::! :, 4 . < `.l.f:^ "1.::' CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> YR-86\1 N 11),bikif cti M tr tAMO S PI Pct/ 1, <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> f S 5 u rJ(Lk S j Deed Restriction;CSM <br /> 15 <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 66 X35 C6 I• J443_q i 1 s c- ("011 6 ' 't- , ^ ' <br /> -Loin ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION T 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) LI 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.usa <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> G NUMBER J-5 05 t- c frontage drawn to scale. ' <br /> i3G'C'1 -1 et-4 1 15 •S <br /> TOWNSHIP: SECTION: <br /> _v7LANb ..5- 1/4: 1/1/: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> .,- T ,� -41,M <br /> ,-,,,,T51-: <br /> '"PROJECT DESCRIPTION: k E gUlL�l (.44 .44,, FEW n/4._ 6/ U/j � , � <br /> r±1, b P <br /> ❑This project is a new building or structure. Fi l <br /> !- gbtn <br /> ❑This project is an addition/alteration to an existing building or structure. ,e <br /> SANITARY SERVICE: PERMIT NUMBER: �'�--�`� �'l � ' <br /> ❑SEWER ❑SEPTIC 4�t-"'S <br /> j„ HEIGpHT IN FEET NUMBER OF STORIES: (Not including basement) - - <br /> 5014 t 5 .c-eg;A— Ra ® � , t i'` <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , �,t "• - ' , .-. <br /> BASEMENT: 1ST FLOOR: ' } :� '. " <br /> �, TOTAL SQUARE FOOTAGE: 4, s° w g,T - <br /> r i' -, - <br /> 2ND FLOOR: 3RD FLOOR: a <br /> x .- <br /> ESTIMATED CONSTRUCTION COST ��� � , <br /> —► —► —► —► —► v Pi ® a®i-4 <br /> (Please round to nearest dollar) $ 1 t I 0 0 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 21<lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑'i o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ErYes ❑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 nonee)�) v <br /> 6. Is a location survey required? (see reverse) ❑Yes UNo P Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />