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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER ME <br /> 1 S 44/0 X2 v 5 E. ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> � V-/ I Variance(# ) <br /> HOOMEE PHONE_ CELL PHONE E-MAI DDRESS/� rm <br /> ,r.,616-?_.o5 • 61/55 Z2g 7St 1" eCTON—J\UFQS� 4(1-PC) ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> GA[k Il cdo 2C9- • ❑ Site Plan including location <br /> AGENT ADDRESS CONTRAC tOR 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: CURRENT ZONING: ACREAGE: <br /> ❑ NUMBER 05 l -011- za\ g R[4 - Z 5--111 3 frontage drawn to scale. <br /> TOWNSHIP. SECTION: <br /> V vti r( R K '/4: '/h: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: g� ' u�LOT SUBDIVISION (�� BLOCK/LOT ❑ Sanitary permits <br /> Q r d� I (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ��� © ©IS 4 <br /> r�dd 57ER 8E15 5-A37;►7l L'9 4rc 1 ' <br /> . ❑This project is a new building or structure/ Ei p. iu.. u <br /> ®'This project is an addition/alteration to an existing building or structure. p , , <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> rat Address n, <br /> f SEWER IEPTIC 1 II ting <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ( Q We and/Floodplaint <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside(Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> E#33��.. r • <br /> BASEMENT: 1ST FLOOR: .` <br /> 5 2r) G d 7 ,`, TOTAL SQUARE FOOTAGE: i ll i'+ t ''g ,°`" "'Al',-ii, <br /> V o (tna rf ) ..,S,:, <br /> 2ND FLOOR: 3RD FLOOR: 2 <br /> I �o7 <br /> CI kes:4w Location Survey <br /> ESTIMATED CONSTRUCTION COST: $ /l and available o , <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ � �w �a! <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 111No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Oho ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑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 1"No ❑Don't know <br /> 7. Is this to correct a violation? El Yes ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -+ <br /> 545-112(4/08) <br />