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*4- 3 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Lawe,1% H C tern r^°n5 ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 4111 Lai S 32aeh ck a me ..-1,4 tv/ S35S'e Variance(# ) <br /> HOME PHONE 'CELL PHONE E-MAIL ADDRESS <br /> (,oS-li9 • SiS-71 <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME y� CONTRACTOR NAME <br /> skc u. )(\it c ens 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 1,12-1 6 cri i4 .,y 51 <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> f Nc.c-wrl014 , Lai 53552 <br /> PHONE PHONE ❑Site Plan approval from <br /> '.103 - 305 - r$5? applicable township. <br /> E ILADDR S E-MAIL ADDRESS <br /> S 0. A Vi}rUJ+t►t1ttY15, <br /> ❑Floor plans to scale <br /> ■ <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEUMBEL <br /> NR pbt0- q4-1 -TOC D' 9 frontage drawn to scale. <br /> TOWNSHIP: SECTN: <br /> . r(3 WIN) `fl �V AVt‘.1 1/4: 5t 1/41/4: 1,1 e ❑Driveway permits <br /> ADDRESS: ` f �j (state,county,town) <br /> a.1.3.77 u5 LOT�`o�v)v- / 5'BDNIS1oN BLOCKILOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: 1 I <br /> ' <br /> 400Q ttc,u' 3a x el[P ❑ Zoning District <br /> This project is a new building 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 /> \1 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ❑ <br /> ErosionControl permit <br /> ,, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ESTIMATED CONSTRUCTION COST: ` ❑ Review Location Survey <br /> ♦ -. -0 -r -0 -0 and available options. <br /> (Please round to nearest dollar) g `(� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Res Dlo 00on't know <br /> 2. Is there a wetland or floodplain on or near the property? es o Jon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ekes 'Jo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres laio <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) Efres girslo Jon't know <br /> 7. Is this to correct a violation? ®Yes I-310 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ♦ ♦ -► <br />