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SUPPLEMENT to Web-App # <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CU•TOMER TO PROVIDE <br /> OWNER NAME <br /> 3-6 11 13 P Z;e, 1 YL <br /> OWNER DDRESS (Number, re t,City,Sta Zi �� oning Status; CUP; <br /> q, y, y� �, eed Restriction; CSM <br /> HOME PHONE c c PHONE E / PnnaI�LLADDR s 1 w (4)/5.C- <br /> 668 �`3� ` Variance(# ) <br /> - y� 2 • 33S- lam �7� ,i3 6' 60-)0 S'a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd• eludes dimensions <br /> AGENT NAME CONTRACTOR NAME / <br /> po,l \ 5 1 L-1—( Sd zi rv°R t'p r Sit Plan including location <br /> AGENT A RESS CONTRACTOR ADDRESS / of ell/septic <br /> �8 � fey �ff <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> cJ't0011i1oit) Lvi5C <br /> PHONE PHONE ❑ - e PI approval from <br /> 665 * i/V --2,jOj ppl' able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ONING: ACREAGE: p p y <br /> ❑ NUMBER 057007e8036, R ( g frontage drawn t cale. <br /> TOWNSHIP: + / SECTION: 'A ' (� <br /> /? ' N "V ' IA: 1 ❑ Drivew ermits <br /> ©LW �a: <br /> ADDRESS: (stat ,county,to ) <br /> 1 ' -5 5 11 17 14(1,) /t_I ❑ Sanitary rmits <br /> CSM: L/� LOT / SUBDIVISION BLOCK/LOT (p,.li ,private) <br /> PROPOSED PROJECT INFORMATION ' <br /> PROJECT DESCRIPTION: <br /> 50K / I tom- le er (d , i sv <br /> . cg3 This project is a new buildin or structure. a,,-emitted Use? <br /> ❑This project is an addition Iteration to an existing building or structure. T <br /> L,SANITARY SERVICE: PERMIT NUMBER: $ <br /> nSEWER EPTIC �€ <br /> , <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not i cluding basement) <br /> z i UW#3€ i! rsr9s '/ <br /> Sheer d (Mttal0. tea. <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) vix ' % <br /> BASEMENT: 1ST FLOOR: <br /> 31/I 6 1 TOTAL SQUARE FOOTAGE: * -�-'disturbance, <br /> 2ND FLOOR: 3RD FLOOR: �,4 9 <br /> 3' Review Lin 0 <br /> ESTIMATED CONSTRUCTION COST: Obi avaiable option ; ', <br /> ♦ ♦ -► -► -* p ,, <br /> (Please round to nearest dollar) a j d�� <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 iNo ❑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 ONo <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) Eyes No ['Don't know <br /> 7. Is this to correct a violation? ['Yes No <br /> - � �1.440Z 545-112 Iaioa> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► <br />