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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION C -TOMER TO PROVIDE <br /> OWNER NAME <br /> sc --/-6.IE 9` 41■046T7E L65-4_ n Zon. g Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D d Restriction;CSM <br /> ,23a2,5 cJ/1-1-/4 'is PR s70?"6i` M £d/ S3.c 9 riance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> &O5)5--7-6*6 beta()f--,Sea Sc,'? a) 'lilac/(C Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Tj Co 15-ricu C7?OA/ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /v1375? 64.6,F2,) <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> / fQit//2-0 a)/ 3-✓ <br /> PHONE PHONE ❑ " e Plan app al from <br /> 64$ 3a$-414a-a p licabl wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loon plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRE ONINt ACREAGE: <br /> ❑PARCEL 061/—OG/—91'D_S VVVV C7^- frontage dra to scale. <br /> NUMBER O <br /> TOWNSHIP: SECTIO <br /> t� Sf,TT Riitl G S I : A) F ,,,,,,:,_5t,\) <br /> ❑Drive y permits <br /> (st ,coun -town) <br /> ADDRESS: 1 R 5 \ �+ I t ' tA W <br /> CAX) t r ❑Sanit permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (r ic,private) <br /> PROPOSED PROJECT INFORMATION •TAFF REVIEW <br /> PROJECT DESCRIPTION: � (�„ �• <br /> - 2Oe b,D( 8 7 III C Z. ing District <br /> . <br /> This project is a new build' g or structure. LI Permitted ? <br /> ❑This project is an additio /alteration to an existing building or structur <br /> SANITARY SERVICE: PERMIT ❑ ral ddress <br /> EWER EPTIC v ( eW/ XlSting <br /> HEIGHT IN FEET: a/ NUMBER OF STORIES: (Not including basement) Wetland/FIOOdplaln/ 't€ <br /> 1 Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ❑ ErosionControl permit /�, <br /> BASEMENT: 1ST FLOOR: v <br /> 4 TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: . .3ao7'I <br /> ❑ Review Location Survey kin ESTIMATED CONSTRUCTION COST: -•► -_► ♦ � ♦ �� nd available options. <br /> (Please round to nearest dollar) / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? s o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Ies f 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? f 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? ❑Yes ®No <br /> 545-112(4/08) c) 7 APPLICATION MUST BE SIGNED <br /> () 0 (Continue on Back) <br />