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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 /> I-an rgl lvf e"h l`- tn C 1.7v7on 5.ewe(-t- oning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) eed Restriction; CSM <br /> q62 K;r,210 ef,i-,n ca',(- 5.4,7 ( -fro,' 53510 ariance(# ) <br /> HOMER O J C+L PHONE E-MAIL ADDRESS tA.(e no7xm vIaa:I. •� <br /> q ‘ / <� L.,...• <br /> i s i nne, e w f edk Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION (and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> an(,o(e Can y}(t•uc.*:o ? la Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> awl(' 5c,17,7c,'a• pe144 <br /> (City,State,Zip). (City,State,Zip) etbacks <br /> eh.'1U1a).on, 1,.-1 53562 <br /> PHONE PHONE Site Plana royal from <br /> 6,01s-`d34-96a l - , applic a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> e o k 1.er,en m4 (a)04,1 S vn•.�'>ors• Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) �jlevation of ro ert <br /> PARENT PARCEL NUMBER: CURRE ZONI G: ACREAGE: P P y <br /> PARCEL ronta a drawn to scale. <br /> NUMBER 014-0810 -oil k.-`S520-o N J•.5a Z g <br /> TOWNSHIP: SECT N: � <br /> 0 IA(kG — 1/4: z=- 1/41/4. 3E icri veway permits <br /> ADDRESS: <br /> (state,county,town) <br /> Cp f 1 $or�tftcf Vg t ley C;CC It Sapitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 13367 (I blic,private) <br /> PROPOSED PROJECT INFORMATION 'STAFF REVIEW;;" <br /> PROJECT DESCRIPTION: '"•` <br /> 1—) y '� E coning District <br /> This project is a new building or structure. <br /> ❑ P rmitted Use?. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMI BERG �^ r ur IAddress <br /> FIEWER i5EPTIC '��pO��0/ 5 ' (, Q ) (ne existing) " <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) «, - <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachme t) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑'ErosionControl permit <br /> TOTAL SQUARE FOOTAGE: ,, (slopes,;disturbance, .-..e <br /> 17 �� 1_ ' filling/access) <br /> 2ND FLOOR: 3RD FLOOR: S <br /> z .Review Location Survey'`" <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ /(�/' , /5() and available options(Please round to nearest dollar) v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes DNo ®Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes ONo ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? K]Yes DNo <br /> 4. Has there been a.zoning permit issued for this property in the past 5 years? Dyes 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 NI o DDon't know <br /> 7. Is this to correct a violation? Dyes !No <br /> k- APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(8/09) <br />