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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com r <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> � <br /> Chr t �l ly 1wvtS PA)Q �0d ❑Zoning Status; CUP; <br /> OWNER ADDRESS Number,Street,City,State, p) V Deed Restriction; CSM <br /> 0? J� 1tYvY� IJC 1� iR�(UYIGL�QQ ( 5 �7 Variance(# ) <br /> HOME PHONE CELL PHONE E-M IL ADDRESS <br /> r )A (AA 51L' 1111 7trY.O e 'IrvlaA •Cam ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> )A f k ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURREN ONING: ACREAGE. <br /> ❑PARCEL �1 909 �/ Ono/1 v._ 1 iJ D I�;C j frontage drawn to scale. <br /> NUMBER l; I J l� Ci 111 <br /> TOWNSHIP: SECTION: <br /> I O'.fw . '/4: '/4'/4: ❑ Driveway permits <br /> AD RESS: 1,,, . (state,county,town) <br /> 60.3 0%eir& b� '` �` 5551 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> g rata& <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: L.ADAIVOn C <br /> - (}t,r I r ✓; (iv ❑ Zoning District <br /> . ❑This project is a new building or structure. t �� ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVIC . PERMIT NUMBER: ❑ Rural Address <br /> IV EWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) <br /> JJn ❑ Wetland/Floodplain/ <br /> l!/ 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 1---1 Erosioneontrol permit <br /> 4, TOTAL SQUARE FOOTAGE: 4 (slopes,disturbance, <br /> — <br /> 2ND FLOOR: 3RD FLOOR: - filling/access) <br /> 3a ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -0. ♦ -0. -. -0. ♦ and 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? ❑Yes [ o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ✓❑f o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes alo /'1)4 <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes DI() <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 Lam"" ❑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 />