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110 SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> J4 M C$ r i1< i 135'1 13 1 v 1'ti en 01 a ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 3 ) 14 V g n c SSoI W 4'1 Sv7 Pro;r i- W� D Deed Restriction; CSM <br /> S. 3 S°1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (1109-12- /3/7 (paS'- , 't -1,72.3 ❑ Site Plan dra�nt�scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includes dtq(ensions <br /> AGENT NAME CONTRACTOR NAME <br /> )4(1-1 P'°1,. / 5/)91 ❑ Site Plan incl ing location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/se <br /> 11 W. )1 o#, ?Iv s+ P a PX VG , <br /> (City,State,Zip) (City,State,Zip) ❑ Setcks 0\1,,,,, / ,' r <br /> 0;1 f ill. iv/. .S3 I '1 q <br /> PHONE PHONE ❑ Site P1 ad! • al from <br /> o7- 9 ,3 - ,u 1`1 appli a :t nship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r h4i k-c..I1 e. ../i pool 3, ca,-1 ❑ Flopkiakto scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCE R: 3 <9)55-ZONING: ACREAG . <br /> ❑ Elev.ti: t roperty <br /> ❑ PARCEL C� , <9)55-ZONING: ' fro a: dr,wn to scale. <br /> NUMBER CWT <br /> TOWNSHIP: SECTION: <br /> 2) '\ D\ 1/4: '/4'/4: ❑ Driv: .� its <br /> ADDRESS: �,(. \ (Star, ,' ,town) <br /> 3,'"\ "&�1e�,,C, ❑ Sanitary permits <br /> SU <br /> CSM: LOT SUBDIVIS N BLOCK/LOT <br /> (public,p . e) <br /> PROPOSED PROJECT INFORMATION ,T F REVIEW <br /> PROJECT DESCRIPTION: <br /> i 1 0 zonlnl y <br /> . RThis project is a new building or structure. i 4/ <br /> 1.1.1 Perin <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> LISEWER (new/e 9 °°) a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> n°' 't .Plain/ <br /> AREA TO NEAREST SQUARE FOOT: '' n11 t1 <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) . <br /> BASEMENT: 1ST FLOOR: p�' <br /> Jv+S(DD <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes, • - femme, <br /> 2ND FLOOR: 3RD FLOOR: � � i',{� ae �� <br /> 0C) <br /> ESTIMATED CONSTRUCTION COST: ReVie ►'Yon Sawa <br /> (Please round to nearest dollar) ♦ ♦ -♦ ♦ ♦ ♦ $ Q/ b d 0 - 0 t 'an '° options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes la No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ['Yes 1 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 El No ❑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 />