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f?r; D SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O NAME . <br /> h� f { _ ❑ Zoning S atus. P; <br /> ON A�° ESS (N ber( itreet,city a Zip) <br /> I 2 G� Deed Re tr Ion; CSM <br /> �)5 ( Variance ) <br /> HOME PHONE CELL P E E-MAIL ADDRE S <br /> 1 U ). �J � S l <br /> , I5 Cn ! a d �h 41 )-(I' i ❑ Site Plan drawnipietale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includ44.1ffiensions <br /> AGENT NAME CO TRACTOR NAM <br /> C- f q <br /> r <br /> (l i f / Site Plan including <br /> l <br /> u <br /> ding lo <br /> cation <br /> AGENT ADDRESS ,____Of Wei/S?Dtir QT yA , 30),(City,State,Zip) (C tyiState,zip) �1 5 3) 5 ❑ Setb�ke/ <br /> f (Th k ❑ SiteP :par PHONE P Q E l S U � <br /> appli•.le aw ship: <br /> E-MAIL ADDRESS E-MAIL ADD R ESS <br /> V-01 oil k.a CIk/1> bt-lt/dih <br /> , t,6Y11 ❑ Floor a o scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usi) ❑ Elevatio Of rty <br /> PARENT PARCEL NUMBER: CU N ZONING: ACREAGE: <br /> ❑ NUMBER o 1°9 -a73-1)(01- 0 _ /1- a 1) frontag awn to scale. <br /> TOWNSHIP: y� SECTION:_ l <br /> VI )1 ' I '/4: 1/41/4: ❑ Drive ay <br /> ADD SS (staff, •,-u ty,t wn) <br /> � ()d– p�IIIUt1 �� wa wmokct° wI qc1 Sani :CSM: LOT SUBDIVISION BLOCK/LOT (p / ) is. <br /> t�) + <br /> 0 • <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECTjI ESCRIPTION: <br /> 'J <br /> /n^ J 'y^' -....1.1., 6 IS „ <br /> . .Lis project is a new building or structure. D P°_ i. '" /,-."'''' v- <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> IvSANITARY SERVICE: PERMIT NUMBER: #°r <br /> 4 ne F1SEWER (SEPTIC nevlw a { u <br /> HEIGHT IN FEET: A„„ ..2c\ NUMBER OF STORIES: (Not including basement) o w ?:' <br /> a. •r <br /> AREA TO NEAREST SQUARE FOOT: ); <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) j k <br /> BASEMENT: 1ST FLOOR: E • • rr re, t <br /> /wjw j TOTAL SQUARE FOOTAGE: j (SopeS, > • r��. � ,��� <br /> f�ngIa s ) .-. <br /> 2ND FLOOR: 3RD FLOOR: "7 (� i�p <br /> ESTIMATED CONSTRUCTION COST: $ a •, E•# 4 <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ ç n C3 00 <br /> 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 EiNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Olio <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank ii none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 1.No <br /> C\)611\V-lkdc- C,61-y\ . — �APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br />