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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNERME <br /> ✓ <br /> � ' � �d/u t' / � ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City, tate,Zip) <br /> 3155 Go R 2 I} Lo✓o..ia/ c.vs s35-5°) Variance V Deed Restriction; CSM ) <br /> HOME PHONE� CELL PHONE E-MAIL ADDRESS <br /> G • -o ! 3 6 710 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Dc q s 5 4 j,,,G ,,❑ Site Plan including location <br /> AGENT ADDRESS CO TRACTORADDRESS of well/septic <br /> PO aO 'V <br /> (City,State,Zip) (C tate,Zip) _ _ ❑ Setbacks <br /> PHONE PHON I=1 Site Plan approval from <br /> US''1p Y - 73 8 3 applicable township. <br /> E-MAIL ADDRESS E- •IL ADDRESS <br /> ap IQQ,u s d ac. ca `KG:-/,c,doh ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 07 Of-191-3 S_0 A-1 a. 3 L I frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ����llo ,�4: ,41/4: ❑ Driveway permits <br /> (state,county,town) <br /> AD S5 955 Go th / a Up ✓o.✓�.. W T S 35553 ❑ Sanitary permits <br /> CSM: 6 J LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION r2 <br /> PROJECT DESCRIPTION: yy � REVIEW© .e c Ic &-t,sixc /-iia�/ UZoning <br /> . ❑This project is a new building or structure. ® P Use? <br /> pi <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: �• ral Address h <br /> FISEWER SEPTIC new/existing),4;, <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> C2 1 © We o,' g'o• aini <br /> AREA TO NEAREST SQUARE FOOT: ," at <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) s H- <br /> BASEMENT: 1ST FLOOR: � ���� � �� � � <br /> 4, TOTAL SQUARE FOOTAGE: 4, •• diisturbance, <br /> filling/awes,} <br /> 2ND FLOOR: 3RD FLOOR: / /I- <br /> �11U <br /> � = 3v <br /> s A ew l. Sup <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ l y a J,�= � i f r<�g= <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? ❑Yes ❑No M Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No 6 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? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -♦ -+ <br /> 545-112(4/08) <br />