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' t4PC° 11') (T711 9 (AM-61 <br /> 1 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NER NAME l �,� <br /> Robe ri/ B0,,z14 L1J"Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> y , ' ,, / v 0 __/i ✓ ' dJ/ 5"35 Variance(# X77 ) <br /> HOME PHONE CELL PHONE IF-MAIL ADDRESS _,/ <br /> g39,3`/75 J Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME 4 CONTRACTOR NAME <br /> /gam/(.,/icc++, Aeidq B� t'ilpv,5 " ,t G Site Plan including location <br /> AGENT ADDRESS cJ CONTRACTOR ADDRESS of well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> J.. P'/-1;i;r I' kV 5—3-5 7D b <br /> PHONE PHONE . to Plan approval from <br /> 4/L/t/- V77 // %I ap 'cable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Flo r plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER R-1 Rill <br /> TOWNSHIP: / SECTION: <br /> C--01104-06E h,r 9 // 1/4: /\J rn) 1/41/4: /VA) Driveway permits <br /> ADDRESS: ` n / // / (state,county,town) <br /> 4/9,y ,de. Ml ( I/ 'rz /�rrt,./ w/ 35 X 7 IV, <br /> • anitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> sv/r4 (public,private) <br /> PROPOSED PROJECT INFORMATION ' ' <br /> PROJECT DESCRIPTION: : A ` '' - ' <br /> Cl This project is a new building or structure. t,, �� �_0-' <br /> ❑This project is an addition/alteration to an existing building or structure. ,, <br /> SANITARY SERVICE: PERMIT NUMBER: °s ��. <br /> ❑SEWER ❑S et a a m , <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) - . ;_• <br /> i2' �,° f � i � 'l <br /> F � v ,;` <br /> A' • • NEAREST SQUARE FOOT. s , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,,:i < 4 <br /> BASEMENT: 1ST FLOOR: k. $ ° r ,k./1/64 7 Z0 ,j, TOTAL SQUARE FOOTAGE: 4, i .. 3 � �.'1'a <br /> . ,) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 7Z0 <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) 17/. <br /> 1 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? < ❑Yes ®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 they in agreement? ❑Yes ®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 none) <br /> 6. Is a location survey required? (see reverse) ®Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? DYes 71 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545112(4/08) <br />