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1k5 / 5V.a s}j w Oe f-d- <br /> ZON1G PERIVII APPLICATION vwvwcartyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Shawn awn Q Yvi 1-ra C 1j ran ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State ip) p Deed Restriction;CSM <br /> H(tufem.) 513a"�LL P , kt4)V~p A1�)1∎04 ` ,1L 53-its Variance(# ) <br /> '—"— , 19 S e, _ gi. ShmotbrOCYS311y9 Q •ma).COAll ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Fic4 Fee.Nate. 'fkilicieg5 ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR�ADDRESS of well/septic <br /> V=O. c$I�' & 3 <br /> (City,State,Zip) (City State,Zip) ❑Setbacks <br /> -i-qc .C tYGVe j wl <br /> PHONE PHONE ❑Site Plan approval from <br /> to OS_ R25-131 , applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> «ccJJ <br /> los €S 4 c'u'ki.c* ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: (Al <br /> ❑PARCEL t A r►�,, frontage drawn to scale. <br /> NUMBER 011 (-2(py- S�"f0O-0 '[Z 'i, a-45- <br /> �-4 J <br /> TOWNSHIP: SECTION: <br /> C VV(1.c Cell 2li ,/4: ,/Q,/: El Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT A SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> Ii(010 l (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Yl£VN Cam+∎eh * I eitcjVitit VI OW_ ❑ Zoning District <br /> This project is a new building or structure. <br /> ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ' ❑ Rural Address <br /> EWER 151EPT1C (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> OWL 44 hck.tl.St ❑ 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 /> BASEMENT: 1ST FLOOR: <br /> ❑ErosionControl permit <br /> 13 W1 3 DO( j TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> U! - filling/access) <br /> 2ND FLOOR: 3RD FLOOR: Z-t 3 <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --o. j � and available options. <br /> (Please round to nearest dollar) <br /> -4 .377. /7 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes fio ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dies (MVo ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes 'lo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) blarn— on <br /> blank if none) <br /> 6. Is a location survey required? (see reverse) C ( L1 Jo ❑C Don't know <br /> 7. Is this to correct a violation? ❑Yes a. <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -+ -► <br /> 545-112(4/08) <br />