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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 /> d/ / .5-r20✓J c ❑ Zoning Status;/CUP;
<br /> OWNER ADDRESS (Number,Street,C y,State,Zip) b,
<br /> 3� 1 II / Deed Restriction; CSM
<br /> / v 6-P K e 2 RcJ /11/4015 w\I 1,v 1 Variance(# )
<br /> HOME PHONE CELL PHONE 1E-MAIL ADDRESS C v�y1
<br /> b8(0 - 7 I r; 54r-0/) - 7 e _ ^'14r • ❑ Site Plan wntoscale
<br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> H-O Mp r.7„‘1,-t-C r ❑ Site Plan/' cluding location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/Weptic
<br /> 5c,,,,,..e as 410 o,J•-e_
<br /> •(City,State,Zip) (City,State,Zip) _❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan r I from
<br /> applicabl ip.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS ' /
<br /> ❑ Floor plan`s to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation 9,f PARENT PARCEL NUMBER: CURRE T ZONIN/7: ACRE,A/GEC: G? frontage n t scale.
<br /> / ❑ NUMBER O14/ (7c�310—lD`--�I330^I_ �_ '' (4 1
<br /> TOWNSHIP: SECTION:
<br /> l3 J ! K-e____ .1/4: 1/1,/: ❑ Driveway permits
<br /> ADDRESS: II (state, coYanty,town)
<br /> 3-20 y 140 e ker ( d /YI015 c ' (-/`J 1 537 1 6 ❑ Sanitary =i'•'ts
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> (public i la.-)
<br /> PROPOSED PROJECT INFORMATION
<br /> PROJECT DESCRIPTION:
<br /> K A • t 5-s a ..F.'" '"a
<br /> r74„ ,4„,,,,,,„ )),,,,,,,,- ice,
<br /> • ❑This project is a new building or structure. T
<br /> 1 Pe�litsat Use?
<br /> 12f-his project is an addition/alteration to an existing building or structure.
<br /> SANITARY E13VICE: PERMIT NUMBER: L3 pita(AddI ss
<br /> 'G�.EWER 1 Sr�PTIC � (� / i ° ) ,,
<br /> HEIGHT IN FEET: �r33 NUMBER OF STORIES: (Not including basement)
<br /> U Wetland ,., . inl _„
<br /> , '` t)
<br /> AREA TO NEAREST SQUARE FOOT: !,
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> BASEMENT: 1$T FLOOR: ,/ : A�
<br /> ' j TOTAL SQUARE FOOTAGE: '("'•$ ° • nce,
<br /> filtiin i M %'',' s
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> Q Re vie , s€"• stitoy
<br /> LA...) , y ESTIMATED CONSTRUCTION COST:
<br /> (Please round to nearest dollar) -0. '♦ -iii. -ii. -II. $ t o O 6>
<br /> S
<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 1:".1--No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? 2Yes ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ErNo
<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 2 No ❑Don't know
<br /> 7. Is this to correct a violation? El Yes 12 o
<br /> AST BE SIGNED
<br /> (Continue PPLICATION on BacMUk) -+ -0 -►
<br /> 545-112(4/08)
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