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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 /> /3'd6'P r 4.4/ -er r.075 e/ ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction; CSM <br /> 7. 2 5` X u_sr'r /'Pa a c/ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 0% — -a- rdi , . ..,, , , ....2o/2 . 4. • .co,. ❑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 /> •IL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRE�NTZONIN ACREAGE: <br /> ❑NUM ER ' e 9/1` 1 y0 -8640-15' ,9--2C') g i Z frontage drawn to scale. <br /> i <br /> TOWNSHIP: SECTI N: <br /> ,e 151-0 ( 1/a: SW 1/'/a: El Driveway permits <br /> ADDRESS: I S (state,county,town) <br /> CSM: LOT i SUBDIVISION BLOCK/LOT Sanitary permits <br /> 3 8 Sc- (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: A � <br /> J70LT ..$ E10 C Zoning Distri <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. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER 'EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> �� <br /> Ca Wetland/Floodplain/ <br /> — 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: Q,EroslonContrpl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> c0Gr sc' 0 ReviewCocation3Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and e'ivailcnt(2(e options. <br /> (Please round to nearest dollar) $ 7-'7, (00 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes f f�lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['es ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? V (es ❑ to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [(/]Yes D. <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# /07/a) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) es aro ❑Don't know <br /> 7. Is this to correct a violation? [Yes 31D <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -+ - <br />