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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 /> G(//CG/II M 116,e T 7_ <br /> E ❑ Zoning Status; CUP; <br /> OWNER ADDRESS umber,Street,Cit fate,Zip) �+ <br /> 7269 ADDRESS <br /> 4Alb -1/i►/ i ia)4/414/6- ograOAT 4/ Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 105- 5= 1 <br /> , 76'78 -' ?f 7g 7 s357�" <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ 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 /> N <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ NTMCEL BER O O5�O-asp. Q50/„ ` Rif / 3 frontage drawn to scale. <br /> UM <br /> TOWNIP: SECTION: './ <br /> / UI4LA A./..0 5- Alk A: if/&''' %IA: ❑ Driveway permits <br /> AD RESS: ,, ) (state,county,town) <br /> 'f249 wr�9,'OeichIi 7pk/ry/✓.t/'" /( ©iEGO 4) „� ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION '' <br /> - _=fir ` -:r. � ��, <br /> PROJECT DESCRIPTION: <br /> ,1G. SrO c ged)a CCU Efik i 8 L „14-' <br /> . ®This project is a new building or structure. <br /> Permitted, Use? <br /> ❑This project is an addition/alteration to an existing building or structure. ;>U f <br /> r4SANITARY SERVICE: PERMIT NUMBER: �r v r "ss < y <br /> SEWER ❑SEPTIC f,j; On 4 ) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1/ El Wevand/F w <br /> eland (a � <br /> AREA TO NEAREST SQUARE FOOT: $�� ' '” <br /> a <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1STFLO R: <br /> **tilt TlI ' <br /> J0 )(5`i / j TOTAL SQUARE FOOTAGE: � 'i -'.,d.0 t7,I 1�s <br /> SGT) <br /> 2ND FLOOR: 3RD FLOOR: , <br /> U R on Survey <br /> ESTIMATED CONSTRUCTION COST: Q cv � , • <br /> (Please round to nearest dollar) $ *35-0,- 9 o z 3 4. . <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 g No ❑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 IK]No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -+ <br /> 545-112(4/08) <br />