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SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Kett//J Hu14/1 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number, treet,City,State,Zip) <br /> 17`!/ ELRO5E S� )42/5c. C� J Deed Variance Restriction; CSM <br /> 7 ✓ �/ � Variance(# ) <br /> HOME PHONE CELL PHONE >>l�4 E-MAIL ADDRESS � <br /> rP..- 1,98 91N Ka/ri:wAdI-n^�' K -' COQ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAM ., <br /> ,QLDr4 i/dR77y /Z5 ❑ Site Plan including location <br /> I AGENT ADDRESS CONT CTOR ADDRESS of well/septic <br /> 9x07 V C/, ir"l K /IV <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> 176eoN4 it/ <br /> PHONE PHONE �� a�.. El Plan approval from <br /> (4 <br /> 060 j,3,�� applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusn El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONIN / ACREAGE: <br /> „ PARCEL ,+t[�/_gyp ) /_ Q / )� ,(/ —/ -j_o5 1 frontage drawn to scale. <br /> NUMBER V�J�S' 6.78// `3 / l lJ 0 is[ / <br /> TOWNSHIP: SECTION: <br /> 70A/A/6`= . eN ,Af 1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 49/6 o va/, ) -- <br /> CSM: LOT SUBDIVISION BLOCK/LOT n Sanitary permits <br /> /03 3A (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> \,ff <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> /3 �(^f/5 _ , ' (new/existing) <br /> SEWER '' !! PTIC 2_/J <br /> HEIGHT IN FEET: / � `` NUMBER OF STORIES: (Not including basement) <br /> 3 O /' S' ❑ 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: ❑ ErosionControl permit <br /> 023 3`152_ 1 TOTAL SQUARE FOOTAGE: 1 (slopes,disturbance, <br /> 2ND FLOOR: C_ 3RD FLOOR: O�� I filling/access) <br /> ` <br /> >(...,, ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: �5���Q� and available options. <br /> –' - <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 '\lo ['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? -,Ye ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Vo <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) ❑Yes n 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 />